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TRUST

COURT OF COMMON PLEAS OF

ORPHANS’ COURT DIVISION

NAME OF TRUST

(TRUST UNDER WILL OF ______________________________________________

or

TRUST UNDER DEED OF _____________________________________________

DATED

)

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 Trust Accounts. If

space is insufficient, riders may be attached. Attach the papers required under items 2, 4,

15-19, as applicable, and any instrument pertinent to the adjudication.

INCLUDE ATTACHMENTS

AT

THE BAC

K OF T

HIS

FO

RM.

Name of Counsel: ________________________________________________________________

Supreme Court I.D. No.: ___________________________________________________________

Name of Law Firm: _______________________________________________________________

Address: ________________________________________________________________________

________________________________________________________________________

Telephone: ______________________________________________________________________

Fax: ___________________________________________________________________________

Email: __________________________________________________________________________

Form OC-02 eff. 09.01.16

Page 1 of 11

Page 3 of 11

Form OC-02 eff.

09.01.16

Name of Trust:

Please note:

A detailed explanation of issues checked should be set forth at item 15 below.

4

.

Testamentary Trust:

Judicial District or County where Letters were issued:

or

Inter Vivos Trust:

Date of Trust:

Date(s) of Amendment(s):

If Settlor is deceased and letters were not

issued or the personal representative

did not advertise the estate, state dates when the Trustee advertised Settlor’s death and

attach proofs of advertising:

5.

Explain why venue is proper before this Court (see 20 Pa.C.S. § 7714), and why the Trust’s

situs is located in this judicial district or county (see 20 Pa.C.S. § 7708).

6.

A. If any other Court has taken jurisdiction of any matter relating to

this Trust, explain:

B. Is this the first accounting of this Trust? . . . . . . . . . . . . . . . . . . . . . . . . Yes

No

Decedent's date of death: ________________________________________________

Date of Decedent's Will: ________________________________________________

Date(s) of Codicil(s): ___________________________________________________

Date of probate: _______________________________________________________

_________________________________________________________________________

Is this inter vivos trust a Special Needs Trust established under

42 U.S.C. § 1396p(d)(4)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes

No

_____________________________________________________________________

_________________________________________________________________________

_____________________

Page 4 of 11

Form OC-02 eff. 09.01.16

Name of Trust:

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

adjudication of the prior accountings.

7. A. State how each Trustee was appointed:

B. If a Petitioner is not a Trustee (e.g., executor or administrator of deceased trustee, agent or

guardian of an incapaciated trustee), explain:

8. State how and when the present fund was awarded to Trustee(s):

9.

to

.

10.

of Account.)

11.

Period covered by this Account:

Current fair market value of the Trust principal is $______________________ (see page

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@_@

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

State concisely the dispositive provisions of the Trust:

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

_________________________________________________________________________

Page 5 of 11

Form OC-02 eff. 09.01.16

Name of Trust:

1

2

. Explain the reason for filing this Account (if filed because of the death of

a party, state

n

ame of person, relationship

to Trust and date of

death):

13. A. State the amount of Pennsylvania Transfer Inheritance Tax paid (including postponed

tax on remainder interests), the dates of p

ayment and the interests upon which such

amounts were paid:

Date Payment Interest

14.

Describe any questions requiring adjudication and state the position of Petitioner(s) as

to each question and give details of any issues identified in item 3:

15.

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 16 below. If any person is being asked to

represent the interests of another interested party (whether sui juris or not), the person

asked to serve as a representative has been so notified and given an opportunity to

decline pursuant to 20 Pa.C.S. § 7725. In addition, notice of any questions requiring

adjudication as discussed in item 14 above has been or will be given to all persons affected

thereby. If one of the beneficiaries is a trust or estate and any of the accountants is also a

fiduciary of the receiving trust or estate, provide written notice of the Account's filing to the

beneficiaries of the receiving trust or estate, as applicable, if known.

__________________________________________________________________________

B. If any such taxes remain unpaid or are in dispute, explain:

__________________________________________________________________________

Page 6 of 11

Form OC-02 eff. 09.01.16

Name of

Trust:

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. Unless contained in the attached

Notice, attach a copy of the written notice provided to any person who is being

asked to represent another or attach such person’s consent to serve.

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

ell 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 Petitioner(s) or

counsel certifying that such Notice has been given. Unless contained in the Notice

or previuosly attached, a copy of the written notice provided to any perso

n who is

being asked to represent another or such person’s consent to serve 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.

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

Notice has been or will be given to the appropriate representative on such party’s

behalf as required by Pa. O.C. Rule 4.2.

D. If any charitable interest is involved, Notice has been or will also be given to

the Attorney General as required under Pa. O.C. Rule 4.4. In addition, the

Attorney General’s clearance certificate (or proof of service of Notice and a

copy of such Notice) must be submitted herewith or at the Audit or filed before

the date of the last day for filing objections in counties without separate

Orphans' Court Divisions.

16.

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

interest in the Trust (if beneficiary is a trust, name the trust and trustee as the Interested Party),

whether such interest is vested or contingent, charitable or non-charitable. This list shall:

A. State each party’s relationship to the Settlor/Decedent and the nature of each party’s

interest(s);

Name

and Address of Each Interested Party

Relationship and Comments, if any

Interest

E. If the Account before the Court is a Special Needs Trust established under 42 U.S.C. §

1396p(d)(4), Notice has been or will also be given to the Pennsylvania Department of

Human Services, Special Needs Trust Depository and to the applicable department of

any other state that has provided the special needs beneficiary with medical care under a

state medical assistance program ("Department"). In addition, the Department's letter of

no objection (or proof of service of Notice and a copy of such Notice) must be submitted

herewith or at the Audit or filed before the date of the last day for filing objections in

counties without separate Orphans' Court Divisions.

Page 7 of 11

Form OC-02 eff.

09.01.16

Name of Trust:

Name and Add

ress of Each Interested Party Relationship and Comments, if any

B. If any interested party (whether sui juris or not) is not receiving Notice of the

filing of the Account and the Petition for Adjudication/Statement of Proposed

Distribution because another individual is proposed to represent such

interested party pursuant to 20 Pa.C.S. §§ 7721-7726, provide the

information below for each proposed representative. If there is more than one

proposed representative, attach a rider setting forth the information below for

each additional proposed representative:

(i) Name of Proposed Representative: _____________________________________

Describe Proposed Representative's Interest(s) in Trust:

Name of the interested parties or description of the class of interested parties whom

the person named above is to represent and describe such persons' interest in Trust:

(iii) Specify the subparagraph(s) under 20 Pa. C.S. § 7723 authorizing representation:

__________________________________________________________________

(iv) Is there any conflict of interest? . . . . . . . . . . . . . . . . . . . . . . . . Yes

No

If yes, explain conflict and why representation should be permitted:

(ii) Has any person who is proposed to be represented as identified

in the question above notified a Trustee in writing that he or

she objects to such representation? . . . . . . . . . . . . . . . . . . . . . . . . . Yes

No

__________________________________________________________________

___________________________________________________________

_______

If yes, provide Name(s) of Person(s) objecting to being represented:

__________________________________________________________________

Interest

_____________________________________________________________________

Page 8 of 11

Form OC-02 eff. 09.01.16

Name of Tr

ust:

C. 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.

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

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

E.

If

distribution is

to be made to the p

ersonal representative o

f

a deceased party,

state date of death, date and place of grant of Letters and type of Letters granted

___________________________________________________________________

If Proposed Representative has neither consented to act in writing nor declined

in writing to act, provide date of the letter in which Proposed Representative

was notified that he or she is to represent another person or class of interested

parties: ____________________________________

If no, has Proposed Representative declined in writing to

act in the representative capacity as requested? . . . . . . . . . . . . . . Yes No

(v)

Has Proposed Representative provided writen consent? . . . . . .

Yes

No

___________________________________________________________________

Page 9 of 11

Form OC-02 eff. 09.01.16

Name of Trust:

17. If Petitioner(s) has/have knowledge that a Trust share has been assigned, renounced,

disclaimed or attached, provide a copy of the assignment, renunciation,

disclaimer or

attachment, together with any relevant supporting documentation.

18.

If a Trustee’s principal commission is claimed:

A.

If based on a written

ag

r

eement, attach a copy thereof.

B. If a principal commission is claimed, state amount. $________________________

C. If a principal commission

is claimed, state the amounts and dates of any principal

commissions previously paid in prior accounting periods.

19. If a reserve is requested, state amount and purpose.

Amount:

If a reserve is requested for counsel fees, has notice of the

amount of fees to be paid from the reserve been given to the

No

If so, attach a copy of the notice.

20. 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

_________________________________________________________________________

Purpose:

_________________________________________________________________

interested parties? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes

Page 10 of 11

Form OC-02 eff. 09.01.16

Name of Trust:

Wherefore, your Petitioner(s) a

sk(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

pa

Name of Trust:

Page 11 of 11

Form OC-02 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 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).

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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