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Form OC-03 eff. 09.01.16 Page 1 of 6

GUARDIANSHIP OF INCAPACITATED PERSON

COURT OF COMMON PLEAS OF

ESTATE OF

, AN INCAPACITATED PERSON

ACCOUNT OF , GUARDIAN

No.

PETITION FOR ADJUDICATION /

STATEMENT OF PROPOSED DISTRIBUTION

PURSUANT TO Pa. O.C. Rule 2.4

This form shall be used in all cases involving the Audit or Confirmation of the Account of a

Guardian of the Estate of an incapacitated person. If space is insufficient, riders may be

attached. Attach the papers required under items 2, 3, and 5, as applicable, and any additional

decree or instrument pertinent to the adjudication.

INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM.

ORPHANS' COURT DIVISION

Name of Counsel: _________________________________________________________________

Supreme Court I.D. No.: ____________________________________________________________

Name of Law Firm: ________________________________________________________________

Address: _________________________________________________________________________

_________________________________________________________________________

Telephone: _______________________________________________________________________

Fax: ____________________________________________________________________________

Email: __________________________________________________________________________

Estate of

, An Incapacitated Person

Form OC-03 eff. 09.01.16

Page 2 of 6

1.

Name(s) and address(es) of Petitioner(s):

Petitioner:

Name:

Address:

2.

3.

A. Ex

p

lain the reason for filing t

his A

ccount (

if incapacitated person has died, state date

of death, name and address of personal representative and of his or her counsel and

attach a Short Certificate if av

ailable. If incapacitated person has been adjudged to

have regained capacity, state date of Decree and attach a copy. If Account is filed for

any other reason, state address of incapacitated person):

B

.

Is this the first accounting for this

estate

? . .

. . . . . . . . . . . . . . . . . . . . . Yes No

4.

A. Identify each unpaid claim against the incapacitated person or the incapacitated person's

estate and describe each in detail (if none, so state):

Identify any Guardians of the Estate who have not joined in the Petition for Adjudication/

Statement of Proposed Distribution and/or the Account and state reason:

Judicial District or County issuing Adjudication of Incapacity:

Date of Adjudication of Incapacity:

Date of Appointment as Guardian:

Attach copy(ies) of Decree(s).

________________________________________________________________________

_____________________________________________________________________

If not, identify prior accountings, the accounting periods covered, and the dates of

adjudication of the prior accountings.

__________________________________________________________________

___________________________

Estate of , An Incapacitated Person

Form OC-03 eff. 09.01.16 Page 3 of 6

5.

Written Notice of the Account's filing as required by Pa. O.C. Rule 2.5 has been or will be

given to all interested parties listed in item 6 below. In addition, notice of any known

unpaid claim not admitted, all questions requiring adjudication and any requested fees as

discussed in item 4 above has been or will be given to all persons affected thereby.

A. If Notice has been given, attach a c

opy of the Notice as well as a list of the names

and addresses of the parties receiving such Notice.

B. If Notice is yet to be given, a copy of the Notice as well as a

list of the names and

addresses of the parties receiving such Notice shall be submitted at the Audit or

filed before the date of the last day for filing objections in counties without

separate Orphans' Court Divisions together with a statement executed by a

Petitioner or counsel certifying that such Notice has been given.

C. If any such interested party is not sui juris (e.g., minors or incapacitated persons),

Notice of the Account's filing has been or will be given to the appropriate

representative on such party’s behalf as required by Pa. O.C. Rule 4.2.

B. Describe in detail any questions requiring adjudication and state the position of the

Petitioner(s) as to each question:

C. If guardian or attorney fees are being claimed, state amount and the period covered

for the requested fees:

_____________________________________________________________________

Estate of

, An Incapacitated Person

Form OC-03 eff. 09.01.16 Page 4 of 6

B. Identify each party who is not sui juris (e.g., minors or incap

acitated persons).

For each such party, give date of birth, the name of each Guardian and how each

Guardian was appointed. If

no Guardian has been appointed, identify the next of kin

of such party, giving the name, address and relationship of each.

7.

If prescribed by local rule as permitted by Pa. O.C. Rule 2.9, is the

Court being asked to direct the filing of a Schedule of Distribution? . . . . . . Yes

No

__________________________________________________________________

Name and Address of Each Interested Party

Relationship and Comments, if any

Interest

A. State each party’s relationship to the incapacitated person and the nature of each

party's interest(s):

List all parties of whom Petitioner(s) has/have notice or knowledge, having or claiming

any interest in the estate, including the incapacitated person’s heirs at law. This list shall:

6.

C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed

(see Pa. O.C. Rule 5.5).

___________________________________________________________________

Estate of

,

An Incapacitated Person

Form OC-03 eff. 09.01.16 Page 5 of 6

Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties entitled

and suggest(s) that the distributive shares of income and principal (residuary shares being stated

in proportions, not amounts) are as follows:

A. Income:

Proposed Distributee(s) Amount/Proportion

B. Principal:

Proposed Distributee(s) Amount/Proportion

Submitted By:

(All petitioners must sign. Place additional

signatures on a

ttachment if necessary):

Corporate Fiduciary (if applicable)

__________________________________________ ____________________________________________

Name of Corporate Fiduciary Name of Petitioner

___________________________________________

____________________________________________

Name of Representative and Title

Signature of Petitioner

____________________________________________

___________________________________________

Signature of Officer/Representative

Name of Petitioner

____________________________________________

Signature of Petitioner

Estate of

, An Incapacitated Person

Page 6

of 6

Form OC-03 eff. 09.01.16

(Verification must be by at

least one petitioner.)

Verification for Individual Petitioner

The undersigned hereby verifies th

at the averment

of f

acts set

forth

in

the

foregoing

Petition

for

Adjudication/Statement

of Proposed Distribution which are within the personal knowledge

of the Petitioner are true, and as to facts based on the information of others, the Petitioner,

after diligent inquiry, believes them to be true; and that any false statements herein are

made subject to the penalties of 18 Pa.C.S. § 4904 (relating to unsworn falsification to

authorities).

Certification of Counsel

The undersigned counsel hereby certifies that the foregoing Petition for Adjudication/

Statemen

t of Proposed Distribution is a true and accurate reproduction of the form Petition

authorized

by

the

Supreme Court, and that no changes to the form have been made beyond the

responses herein.

______________________________

Date

______________________________________

Signature of Counsel for Petitioner

The undersigned hereby verifies that he/she _________ is title ____________________________

of the above-named name of corporation _________________________________________________

and that the averment of facts set forth in the foregoing Petition for Adjudication/Statement of

Proposed Distribution which are within the personal knowledge of the Petitioner are true, and

as to facts based on the information of others, the Petitioner, after diligent inquiry, believes

them to be true; and that any false statements herein are made subject to the penalties of 18

Pa.C.S. § 4904 (relating to unsworn falsification to authorities).

Verification for Corporate Petitioner

_______________________________

Date

______________________________________

Signature of Petitioner

______________________________

Date

__________________________________________

Signature of Representative for Corporate Petitioner

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