IN THE ORPHANS' COURT DIVISION OF THE COURT OF COMMON PLEAS OF WESTMORELAND COUNTY, PA ESTATE OF Deceased Late of ) ) ) ) ) ) ) No. 65- TESTACY/INTESTACY PETITION FOR DISTRIBUTION TO THE HONORABLE, THE PRESIDING JUDGE OF SAID COURT: The petition of respectfully represents: 1. The decedent died on June 13, 2006, (in)testate, and at that time was domiciled and resided in /Westmoreland/PA (municipality/county/state) 2. Letters (testamentary) (of administration ) were granted on 3. Letters were advertised in , with bond. and in the Westmoreland Law Journal, the first , more than four months before the complete advertisement having been made on filing of the Account. Proofs of publication marked Exhibit "A" are attached. 4. Within three months after the grant of letters written notice was sent to (the following corporations and associations named as beneficiaries in the Will) and (the American LegalNet, Inc. www.USCourtForms.com Commonwealth or political subdivision having a claim for maintaining the decedent in an institution where death occurred) (and) (each beneficiary named in the decedent's Will) (all the intestate heirs). 5. (a) (b) (c) Decedent was married to . . The spouse survived the decedent on There is (no) (an) election by the surviving spouse. (Attach copy) 6. The decedent did marry and no children were born to or lawfully adopted by the decedent after the execution of the will or codicil (as follows): 7. The family exemption of aside.) (Attach exhibit) 8. The estate is subject to Federal Estate Tax (and the same has been paid) (and a closing letter has been received). (Attach copy) 9. The estate is subject to Pennsylvania Inheritance Tax and the same has been paid and a Notice of Inheritance Tax Appraisement has been received. (Attach copy) 10. The estate is subject to Pennsylvania Estate tax (and the same has been paid) and an Estate Tax Determination has been received. (Attach copy) 11. Written notice has been given of the filing of the Account, as well as a copy of the Account and of the time and date for audit to every unpaid creditor who has given written notice of his claim to the petitioner or to the petitioner's attorney of record. The following is a list of all unpaid creditors, together with the amounts of their claims, the category of claim under � 3392 of the PEF Code, and the extent to which their claims are admitted: was claimed by (and the same has been set 2 American LegalNet, Inc. www.USCourtForms.com Name and Address Category of Claim Amount Amount Recommended for Allowance 12. A charitable interest is (not) involved, (and notice was (not) given to the Attorney General on , under Rule 5.5 of the Pennsylvania Orphans' Court Rules, and a response has (not) been received.) (Attach a copy of response, if applicable.) 13. The decedent was an inmate of a public institution (and a copy of the Account, certified by counsel, has been filed with the Pennsylvania Department of Revenue in accordance with Rule 6.7 of the Pennsylvania Orphans' Court Rules). 14. The decedent was a veteran or the child of a veteran entitled to benefits (and a copy of the Account, certified by counsel, has been filed with the United States Veterans Administration in accordance with Rule 6.8 of the Pennsylvania Rules). 15. The decedent did receive medical assistance after August 15, 1994 (and the Department of Public Welfare was given notice in accordance with the provisions of 62 Pa. C.S.A. � 1412). 16. All parties, other than creditors, known to have an interest in the estate as unpaid heirs or beneficiaries, have been given at least twenty days written notice of the filing Orphans' Court 3 American LegalNet, Inc. www.USCourtForms.com of the Account, as well as a copy of the Account and of the time and date or audit (except as follows): 17. (a) The following parties are not sui juris and are not represented: (b) The following parties are in the military service of the United States: (c) Decedent at the time of death was known to be a fiduciary of the following entities: 18. There is no (partial) or (entire) intestacy. (Explain as necessary.) 19. The names and addresses of all persons having any interest as devisees, legatees or heirs, with the names of parents where necessary to show relationship, are as follows: Name and Residence (Give name of guardian, executor, or administrator, if any) Relationship Sui Juris (Yes or No) Living (Yes or No) In the case of intestacy, where the decedent had a surviving spouse and surviving issue, are all of such surviving issue also the issue of the surviving spouse? (Yes) (No) 20. The following is a statement of all changes in distribution under the Will, resulting from the death of persons named as beneficiaries therein, ademption of specific gifts, election to take against the Will or otherwise, together with the date of death of any such beneficiary: 4 American LegalNet, Inc. www.USCourtForms.com 21. Elections to take in kind are as follows: (Attach exhibits) 22. No distribution has been made other than that appearing in the Account or in this Petition, and receipts for all distributions are attached as Exhibit " 23. All personal representatives are petitioners (except ". who (has)(have) been given written notice of the filing of the Account and the audit thereof, as set forth on Exhibit " "). 24. The following is a statement of the combined balance on hand as shown by the Account, together with all additional receipts and disbursements not shown by the Account: (Attach exhibits as appropriate) Combined Balance on Hand, as shown by Account $ Additional assets not shown by Account: Total corrected balance $ Additional disbursements not shown by Account: Corrected net balance for distribution $ 5 American LegalNet, Inc. www.USCourtForms.com 25. The net balance for distribution consists of property of kind, form and character, including as Exhibit " " a full description of real estate to be distributed, as follows: Description of Personal Property Value $ Real property (as described on Exhibit " ") Total (corrected net balance for distribution) $ 26. Other matters requiring adjudication are as follows: 6 American LegalNet, Inc. www.USCourtForms.com WHEREFORE, the petitioner(s) request(s) that a distribution be made by the Court in accordance with the proposed Decree of Distribution submitted herewith. ____________________________________ (Signature and Title) VERIFICATION (I)(We), the undersigned petitioner, verify that the statements made i