Fill - Free fillable PRINCIPALS ESTATE (Under Power of Attorney) COURT OF (Beaver County Information Technology) PDF form

Form OC-05 eff. 09.01.16

Page 1 of 8

PRINCIPAL’S ESTATE

(Under Power of Attorney)

COURT OF COMMON PLEAS OF

ESTATE OF

, PRINCIPAL

ACCOUNT OF

, AGENT(S) *

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 one or

more Agents acting under a Power of Attorney. If space is insufficient, riders may be

attached. Attach the papers required under items 3, 4 and 9, as applicable, and any instrument

pertinent to the adjudication.

INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM.

Name of Counsel:

Supreme Court I.D. No.:

Name of Law Firm:

Address:

Telephone:

Fax:

* The term “Agent” shall include any person designated as an “attorney-in-fact” or acting in a similar capacity by the Principal’s

delegation.

ORPHANS' COURT DIVISION

______________________________________________________________________

Email: ________________________________________________________________________

Estate of

, Principal

Form OC-05 eff. 09.01.16

Page 2 of 8

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

Petitioner:

Name:

Address:

Name(s) and address(es) of Agent(s) (if not Petitioner(s)):

Name:

Address:

2

.

Name and address of Principal (and, if applicable, of any Guardian appointed for Principal,

of each personal representative for any Principal or Agent who has died, and of his or her

counsel, identifying t

he capacity of each):

3.

A. Date of Principal’s Power of Attorney under which Agent(s) acted:

B. Date Agent(s) first exercised control of Principal’s assets under Power of Attorney:

(

Attach copy of each different Power of Attorney granted to Agent(s) by

Principal

and copy of an

y Decree involving Agent(s) f

or Principal).

Agent:

Identify any Agents who have not joined in the Petition for Adjudication/Statement

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

Judicial District or County where Principal resides, or if Principal is deceased, where Letters

were issued:______________________________________________

________________________________________________________________________

Estate of

, Principal

Form OC-05 eff. 09.01.16

Page 3 of 8

4.

A. Ex

p

lain the reason for filing

this Account (if Principal or Agent has died, state date of

death, and attach a Short Certificate; if Principal has been adjudicated incapacitated,

state date of Decree, and attach a copy):

5.

Describe all gifts/transfers for less than full and adequate consideration made under the

Power of Attorney. Identify each recipient’s name, address, and relationship to Principal

and/or Agent, amount of each gift/transf

er, nature of each (cash or kind), and date made,

with any additional explanation deemed appropriate (if none, so state):

6.

Identify every asset or interest (include title or registration and value) of Principal known

to Petitioner(s) and not identified in Account, whether or not in possession or control of

Petitioner(s) (if none known, so state):

B. Is this the first accounting for this Principal's estate?. . . . . . . . . . . . . Yes No

_______________________________________________________________________

________________________________________________________________

_______________________________________________________________________

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

dates of adjudication of the prior accountings.

Estate of

, Principal

Form OC-05 eff. 09.01.16

Page 4 of 8

7

.

Identify each existing safe deposit box of or for Principal and each one closed by Agent(s)

(if not applicable, so state):

Institution & Address

Box No.

Title or Registration Date Closed (if applicable)

Are the entire contents of each safe deposit box identified in item 7

above included in the filed Account? ... ......................... Yes

No

If not, explain:

8.

A. Identify each known unpaid claim against Principal or Principal’s estate and describe

each in detail (if none, so state):

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

Petitioner(s) as to each question:

____________________________________________________________________

Estate of , Principal

Form OC-05 eff. 09.01.16

Pag

e 5 of 8

9.

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

given to each interested party in the matter. In addition, notice of any known unpaid claim not

admitted, all questions requiring adjudication, and any requested fees as described in item 8

above has been or will be given to all parties affected thereby.

A. If Notice has been given, attach a copy 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.

C. If fees are being claimed by the Agent or an attorney, state amount and the period

covered for the requested fees:

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

interest in the Principal's estate. This list shall:

A. State each party’s relationship to the Principal and the nature of each party's interest(s):

_____________________________________________________________________

Name and Address of Each Interested Party Relationship and Comments, if any Interest

Estate of

, Principal

Form OC-05 eff. 09.01.16

Page 6 of 8

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

___________________________________________________________________

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

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

__________________________________________________________________

___________________________________________________________________

11. 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

Estate of

, Principal

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 attachment 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

Form OC-05 eff. 09.01.16

Page 7 of 8

Estate of

, Principal

Page 8 of 8

Form OC-05 eff. 09.01.16

(Verification must be by at least one petitioner.)

Verification for Individual Petitioner

The undersigned hereby verifies th

at the aver

ment

of

f

acts

set

forth

in

the

foregoing

Petition

for

Adjudication/Sta

temen

t

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/

Statement 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.

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

______________________________

Date

_________________________________________

Signature of Counsel for Petitioner

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