In the Court of Common Pleas of York County, Pennsylvania Orphans222 Court Division Estate of : also known as: : No. , deceased : : Petition for Settlement of Small Estate (Gross Estate of $25,000 or less for decedents dying before August 31, 2013) (Gross Estate of $50,000 or less for decedents dying on or after August 31, 2013)Pursuant to section 3102 of the Probate, Estates and Fiduciaries Code, the undersigned petitioner respectfully represents that: 1.The name and address of the petitioner are:2.The relationship of the petitioner to the decedent is:3.The decedent died on:1088175-3 (Rev. 09/18) Page 1 of 114.The decedent was domiciled at time of death in York County, Pennsylvania, with a last family orprincipal residence at: American LegalNet, Inc. www.FormsWorkFlow.com 5.The following are attached hereto: (a) Death certificate is already filed with the Register of Wills. (b) Death certificate is already filed with the Clerk of Orphans' Court.6.The decedent died: (a) Intestate (b) TestateIf the decedent died testate: (i) the will and any codicil(s) has/have been probated, and a copy is (ii) the will and any codicil(s) has/have not been probated, and the 1088175-3 (c) If attaching death certificate, use Confidential Document Form (CDF). (d) Letter from the Pennsylvania Department of Human Services (DHS) as to theoriginal will and any codicil(s) is/are being filed with the Clerk of Orphans' Court. [If not attached, explain.] The personal representative(s) named therein is (are): filed with the Clerk of Orphans' Court. Letters have been issued to:existence and amount of the estate recovery claim. American LegalNet, Inc. www.FormsWorkFlow.com 7.The name(s), relationship(s), and interest(s) of all parties beneficially interested in the estate are: [Give details as to whether the decedent was survived by a spouse, children or step-children. If person is a minor, use Confidential Information Form (CIF) for name.] Sui Juris Name Relationship Interest (Yes or No) 8.A spouse222s elective share: (a) has not been claimed. (b) has been claimed. [Give details.] 9.If the decedent died testate, the decedent: (a) was not married or divorced after the date of execution of the will. (b) was married or divorced after the date of execution of the will. [Give details.]10.If the decedent died testate, the decedent: (a) did not have a child or children born or adopted after the date of execution of the will. 1088175-3 American LegalNet, Inc. www.FormsWorkFlow.com (b) had a child or children born or adopted after the date of execution of the will. [Give the name and date of birth or adoption of each such child. If minors, use initials and Confidential Information Form (CIF) for names and date of birth] Name Date of Birth or Adoption 11.The decedent died owning property (exclusive of real property and property payable undersection 3101 of the Probate, Estates and Fiduciaries Code) of a gross value not exceeding $50,000, (or $25,000.00 if prior to August 31, 2013) which is itemized below. [Include only last four (4) digits of account numbers and registration numbers, etc.]Item Amount Total $1088175-3 American LegalNet, Inc. www.FormsWorkFlow.com 12.An itemized statement of all claims against the estate, in order of preference, is set forth below:(a) The following person(s) claim(s) the family exemption: Amount or Name Relationship Items Claimed (indicate if minors, incapacitated or deceased) If Minors, use initials and Confidential Information Form (CIF) Total $(b) The following persons claim reimbursement for debts, expenses, and other claims (including inheritance tax, if applicable) they have paid with their own funds: Person Claiming Reimbursement Date of Payment Payee Nature of Debt or Expense Amount Total$1088175-3 American LegalNet, Inc. www.FormsWorkFlow.com (c) The following claims remain unpaid: Claimant Nature of Claim Amount Total $13. (a) All claims are undisputed. (b) The following claims are disputed: [Give details.] 14.The petitioner has paid or will cause to be paid all Pennsylvania inheritance tax due on allproperty to be awarded under this petition. If inheritance taxes due have not been paid, the amount due listed in 12 (c) should list the Register of Wills as a creditor. 1088175-3 American LegalNet, Inc. www.FormsWorkFlow.com 15.All parties beneficially interested in the estate, other than the petitioner, including all holders ofclaims that are disputed, or, in the case of an insolvent estate, all holders of claims that will not be paid in full, have either: (a) signed the joinder in this petition which is hereto attached;or (b) been mailed at least twenty (20) days written notice of the date, time, and place of 16.Your petitioner proposes:(a) that the family exemption, if any, be paid or satisfied as follows: (b) that the following claims be paid: [Refer to section 3392 of the Probate, Estates and Fiduciaries Code to establish priority among claims, if necessary.]Claimant Nature of Claim Amount Total $1088175-3 the Orphans222 Court audit session at which the petition will be ruled upon by the Court, a copy of which notice is attached hereto. [See Pa.O.C. Rule 2.5] American LegalNet, Inc. www.FormsWorkFlow.com (c) that the balance, if any, be distributed as follows: Name Amount Total $Signature of Petitioner Typed Name: Telephone Number: Signature of Petitioner Typed Name: Telephone Number: Signature of Petitioner Typed Name: Telephone Number: Signature of Attorney for Petitioner Typed Name: Supreme Court I.D. No.: Office Address: Telephone Number: 1088175-3 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF COMPLIANCEI certify that this filing complies with the provisions of the Case Records Public Access Policy of the Unified Judicial System of Pennsylvania that require filing confidential information and documents differently than non-confidential information and documents.Submitted by: Signature:Name: Attorney No. (if applicable): 1088175-3 American LegalNet, Inc. www.FormsWorkFlow.com Verification The undersigned petitioner hereby verifies, subject to the penalties of 18 Pa. C.S.A. 2474904 (relating to unsworn falsification to authorities), that the facts set forth in the foregoing petition which are within his (her) knowledge are true, and, as to the facts based on information received, after diligent inquiry, he (she) believes them to be true. Date: Signature of Petitioner Signature of Petitioner Signature of Petitioner Joinder I (we), the undersigned, being parties other than the petitioner beneficially interested in the estate and/or surviving spouse, children or step-children of the foregoing decedent, do hereby certify that I (we) have read the foregoing petition and join in the prayer thereof. 1088175-3 American LegalNet, Inc. www.FormsWorkFlow.com In the Court of Common Pleas of York County, Pennsylvania Orphans222 Court Division Estate of : : also known as: : No. , deceased : Order And now, this day of ,20 , upon consideration of the foregoing petition, it is ordered that the petitioner disburse/distribute the property of the decedent under section 3102 (and section 3392, if applicable) of the Probate, Estate and Fiduciaries Code as follows: (If minors, initials only refer to Confidential Information Form (CIF))Name Amount Total $This decree of distribution shall constitute sufficient authority to all transfer agents, registrars and others dealing with the property of the estate to recognize the persons named as entitled to receive such property without administration, and shall in all respects have the same effect as a decree of distribution after an accounting by a personal representative. By the Court, Judge 1088175-3 American LegalNet, Inc. www.FormsWorkFlow.com