PRINCIPAL’S ESTATE (Under Power of Attorney) COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA ORPHANS’ COURT DIVISION ESTATE OF , PRINCIPAL ACCOUNT OF , AGENT(S) * 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 one or more Agents acting under a Power of Attorney. 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: * The term “Agent” shall include any person designated as an “attorney-in-fact” or acting in a similar capacity by the Principal’s delegation. Form OC-05 rev. 10.13.06 Page 1 of 7 American LegalNet, Inc. www.FormsWorkflow.com Estate of 1. , Principal Name(s) and address(es) of Petitioner(s): Petitioner: Petitioner: Name: Address: 2. Name(s) and address(es) of Agent(s) (if not Petitioner(s)): Agent: Agent: Name: Address: 3. Name and address of Principal (and, if applicable, of each guardian appointed for Principal, of each personal representative for any Principal or Agent who has died, and of his or her counsel, identifying the capacity of each): 4. A. Date of Principal’s Power of Attorney under which Agent(s) acted: B. Date Agent(s) first exercised control of Principal’s assets under Power of Attorney: (Attach copy of each different Power of Attorney granted to Agent(s) by Principal and copy of any Decree involving Agent(s) for Principal). Form OC-05 rev. 10.13.06 Page 2 of 7 American LegalNet, Inc. www.FormsWorkflow.com Estate of , Principal 5. Explain the reason for filing this Account (if Principal or Agent has died, state date of death, and attach a Short Certificate; if Principal has been adjudicated incapacitated, state date of Decree, and attach a copy): 6. Describe all gifts/transfers for less than full and adequate consideration made under the Power of Attorney. Identify each recipient’s name, address, and relationship to Principal and/or Agent, amount of each gift/transfer, nature of each (cash or kind), and date made, with any additional explanation deemed appropriate (if none, so state): 7. Identify every asset or interest (include title or registration and value) of Principal known to Petitioner(s) and not identified in Account, whether or not in possession or control of Petitioner(s) (if none known, so state): Form OC-05 rev. 10.13.06 Page 3 of 7 American LegalNet, Inc. www.FormsWorkflow.com Estate of 8. , Principal Identify each existing safe deposit box of or for Principal and each one closed by Agent(s) (if not applicable, so state): Institution & Address 9. Box No. Title or Registration Date Closed (if applicable) Are the entire contents of each safe deposit box identified in item 8, above, included in the filed Account? . . . . . . . . . . . . . . . . . . . . . . . . . . . . “ Yes “ No If not, explain: 10. A. Identify each known unpaid claim against Principal or Principal’s Estate and describe each in detail (if none, so state): B. Describe in detail any questions requiring adjudication and state the position of the Petitioner(s) as to each question: Form OC-05 rev. 10.13.06 Page 4 of 7 American LegalNet, Inc. www.FormsWorkflow.com Estate of 11. , Principal 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 each party in interest in the matter. In addition, Notice of any known unpaid claim not admitted and of all questions requiring adjudication, as described in item 10, above, has been or will be given to all parties who may be affected. A. State the name and address of each such party and that party’s relationship to the Principal. B. If Notice has been given, attach a copy of the Notice as well as a list with the name and address of each party receiving such Notice. C. If Notice is yet to be given, a copy of the Notice as well as a list with the name and address of each party receiving such Notice shall be submitted at the Audit together with a statement executed by Petitioner(s) or counsel, certifying that such Notice has been given. D. If any such party is not sui juris (e.g., 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. 12. Is the Court being asked to direct the filing of a Schedule of Distribution? . . . . . . . . . . . . . . . . . . . . . . . . . . “ Yes Form OC-05 rev. 10.13.06 “ No Page 5 of 7 American LegalNet, Inc. www.FormsWorkflow.com Estate of , Principal Wherefore, it is respectfully requested by your Petitioner(s) that distribution be awarded to the parties entitled as follows: Proposed Distributee(s) Amount/Proportion Submitted By: (All petitioners must sign. Add additional lines if necessary): Name of Petitioner: Name of Petitioner: Form OC-05 rev. 10.13.06 Page 6 of 7 American LegalNet, Inc. www.FormsWorkflow.com Estate of , Principal 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-05 rev. 10.13.06 Page 7 of 7 American LegalNet, Inc. www.FormsWorkflow.com