GUARDIANSHIP OF INCAPACITATED PERSON COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA ORPHANS’ COURT DIVISION ESTATE OF , AN INCAPACITATED PERSON ACCOUNT OF , GUARDIAN No. PETITION FOR ADJUDICATION / STATEMENT OF PROPOSED DISTRIBUTION PURSUANT TO Pa. O.C. Rule 6.9 This form may be used in all cases involving the Audit of the Account of a Guardian of the Estate of an incapacitated person. If space is insufficient, riders may be attached. INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM. Name of Counsel: Supreme Court I.D. No.: Name of Law Firm: Address: Telephone: Fax: Form OC-03 rev. 10.13.06 Page 1 of 6 American LegalNet, Inc. www.FormsWorkflow.com Estate of 1. , An Incapacitated Person Name(s) and address(es) of Petitioner(s): Petitioner: Petitioner: Name: Address: 2. Date of Adjudication of Incapacity: Date of Appointment as Guardian: Attach copy(ies) of Decree(s). 3. A. Explain the reason for filing this Account (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 available. If incapacitated person has been adjudged to have regained capacity, state date of Decree. If Account is filed for any other reason, state address of incapacitated person): B. Have prior accountings been filed? . . . . . . . . . . . . . . . . . . . . . . . . . . . “ Yes “ No If yes, state accounting periods and dates of adjudication. 4. Describe in detail any questions requiring adjudication and state the position of the Petitioner(s) as to each question: Form OC-03 rev. 10.13.06 Page 2 of 6 American LegalNet, Inc. www.FormsWorkflow.com Estate of 5. , An Incapacitated Person Written Notice of the Audit as required by Pa. O.C. Rules 6.3, 6.7 and 6.8 has been or will be given to all parties in interest listed in item 6 below. In addition, notice of any questions requiring adjudication 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 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 together with a statement executed by a Petitioner or counsel certifying that such Notice has been given. C. If any such party in interest is not sui juris (e.g., minors or incapacitated persons), Notice of the Audit has been or will be given to the appropriate representative on such party’s behalf as required by Pa. O.C. Rule 5.2. 6. 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: A. State each party’s relationship to the incapacitated person and the nature of each party’s interest(s): Name and Address of Each Party in Interest Form OC-03 rev. 10.13.06 Relationship and Comments, if any Interest Page 3 of 6 American LegalNet, Inc. www.FormsWorkflow.com Estate of , An Incapacitated Person 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. 7. Is the Court being asked to direct the filing of a Schedule of Distribution? . . . . . . . . . . . . . . . . . . . . . . . . . . “ Yes Form OC-03 rev. 10.13.06 “ No Page 4 of 6 American LegalNet, Inc. www.FormsWorkflow.com Estate of , An Incapacitated Person Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties entitled and suggests 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. Add additional lines if necessary): ___________________________________________ Name of Petitioner: ___________________________________________ Name of Petitioner: Form OC-03 rev. 10.13.06 Page 5 of 6 American LegalNet, Inc. www.FormsWorkflow.com Estate of , An Incapacitated Person Verification of Petitioner (Verification must be by at least one petitioner.) The undersigned hereby verifies * [that he/she is title of the above-named name of corporation and] that the 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). ____________________________________ Signature of Petitioner * Corporate petitioners must complete bracketed information. 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. Signature of Counsel for Petitioner Form OC-03 rev. 10.13.06 Page 6 of 6 American LegalNet, Inc. www.FormsWorkflow.com