DECEDENT'S ESTATE COURT OF COMMON PLEAS OF ORPHANS' COURT DIVISION ESTATE OF________________________________, DECEASED 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 a Decedent's Estate. If space is insufficient, riders may be attached. Attach the papers required under items 1, 2, 4, 8, 10, 16-19, 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: __________________________________________________________________________ Email: ________________________________________________________________________ Form OC-01 eff. 09.01.16 Page 1 of 11 American LegalNet, Inc. www.FormsWorkFlow.com Estate of 1. Name(s) and address(es) of Petitioner(s): Petitioner: Name: __________________________________________ , Deceased Petitioner: ___________________________________________________ ___________________________________________________ ____________________________________________________ Address: __________________________________________ __________________________________________ Identify any Executors or Administrators who have not joined in the Petition for Adjudication/Statement of Proposed Distribution and/or the Account and state reason: ________________________________________________________________________ ________________________________________________________________________ No Is this the first accounting for this estate? . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes If not, identify prior accountings, the accounting periods covered, and the dates of adjudication of the prior accountings. Pursuant to 20 Pa.C.S. § 3501.2, if property from a trustee, guardian, or agent acting under a power of attorney is being received into the estate, an Account of the administration of such trust, guardianship, or principal's estate may be annexed to the Estate Account. Is any such Account annexed to this Estate Account? . . . . . . . . . . .. . . . . . . . . . Yes No If so, the annexed Account and the appropriate fully completed Petition for Adjudication/ Statement of Proposed Distribution for the annexed matter should be filed as Exhibits to this Petition. . Decedent died on Letters Testamentary or Letters of Administration were granted to Petitioner(s) on . 2. Date of Will (if applicable): Date(s) of Codicil(s) (if applicable): Date of probate (if different from date Letters granted): Was a bond required? Yes No If yes, state amount: Are proofs of advertising of the grant of Letters attached? . . . . . . . . . Dates of advertising of the grant of Letters: _____________________________________________________________________ _____________________________________________________________________ Form OC-01 eff. 09.01.16 Yes No Page 2 of 11 American LegalNet, Inc. www.FormsWorkFlow.com Estate of , Deceased Yes No 3. Was decedent survived by a spouse? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, name of the surviving spouse: 4. Has the surviving spouse filed to take an elective share? . . . . . . . . (see 20 Pa.C.S. § 2201 et seq.) If yes, attach a copy of the election and state date of election: Yes No N/A 5. In the case of an intestacy, state the names of the decedent's surviving children or surviving issue of deceased children (if none, so state): 6. Did decedent marry after execution of Will or Codicil(s)? . . . . . . . . . . . . Were any children born to decedent after execution of Will or Codicil(s)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . If yes, give names and dates of birth: Name: Date of Birth: Yes No N/A Yes No N/A 7. Was a request for a statement of claim, as required by the Medical Assistance Estate Recovery Act, 62 P.S. § 1412, sent to the Department of Human Services? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No N/A Form OC-01 eff. 09.01.16 Page 3 of 11 American LegalNet, Inc. www.FormsWorkFlow.com Estate of 8. , Deceased 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 9 below, all unpaid creditors and all claimants listed in item 10 below. In addition, notice of any questions requiring adjudication as discussed in item 15 below has been or will be given to all persons affected thereby. If one of the beneficiaries is a trust or another 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 trust or receiving estate, as applicable, if known. 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 person 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. 9. List all parties (charitable and non-charitable) of whom Petitioner(s) has/have notice or knowledge, having or claiming any interest in