PRINCIPAL’S ESTATE 
(Under Power of Attorney)

COURT OF COMMON PLEAS OF

ORPHANS' COURT DIVISION
 

ESTATE OF 

ACCOUNT OF

No.

, PRINCIPAL , 

AGENT(S) *

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  one  or  more  Agents  acting  under  a  Power  of  Attorney. 
If  space 
is insufficient,  riders  may  be attached. Attach the papers required under items 3, 4, 
and 9, 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:

delegation.

______________________________________________________________________ 

Email: ________________________________________________________________________

* The term “Agent” shall include any person designated as an “attorney-in-fact” or acting in a similar capacity by the Principal’s

Form OC-05  rev. 01.01.20

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Estate of

       , Principal

1. Name(s) and address(es) of Petitioner(s):

Petitioner:

 Petitioner:

Name:

Address:

Name:

Address:

Name(s) and address(es) of Agent(s) (if not Petitioner(s)):

Agent: 

Agent:

Identify any Agents who have not joined in the Petition for Adjudication/
Statement of Proposed Distribution and/or the Account and state reason:

2. Name and address of Principal (and, if applicable, of any 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):

Judicial District or County where Principal resides, or if Principal is deceased, where 
Letters were issued:______________________________________________

3. 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). 

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Estate of

       , Principal

4. A.  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 
 incapacitated,  state date of Decree, and attach a copy):

B.

Is this the first accounting for this Principal's estate? . . .           Yes           No
If not, identify prior accountings, the accounting periods covered, 
and the dates of adjudication of the prior accountings.

5. 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):

6. 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):

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Estate of

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7.

Identify each existing safe deposit box of or for Principal and each one closed by Agent(s)
(if not applicable, so state):

Institution & Address

Box No.

Title or Registration

Date Closed (if applicable)

Are the entire contents of each safe deposit box identified in item 7
above included in the filed Account?  . . . . . . . . . . . . . . . . . . . . . . . .

 Yes   

  No

If not, explain:

8. 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:

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C. If fees are being claimed by the Agent or an attorney, state amount and the period

covered for the requested fees:

9. Written  Notice  of  the  Account's  filing  as  required  by  Pa.  O.C.  Rule  2.5  has  been  or

B.

A.

will  be given to each interested party in the matter.  In addition, notice of any unpaid
claim not admitted,  all  questions  requiring  adjudication,  and  any  requested fees  as
described  in  item  8 above has been or will be given to all parties affected thereby.
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.
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.
If any such interested party is not sui juris (e.g., minors or incapacitated
persons), Notice of the Account's filing has been or will be given to the
appropriate representative on such party's behalf as required by Pa. O.C. Rule
4.2.

C.

10.

List all parties of whom Petitioner(s) has/have notice or knowledge, having or claiming
any interest in the Principal's estate.  This list shall:

A. State each party’s relationship to the Principal and the nature of each party's

interest(s):

Name and Address of Each Interested Party Relationship & Comments, if any

Interest

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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.

C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed

(see Pa. O.C. Rule 5.5).

11.

If prescribed by local rule as permitted by Pa. O.C. Rule 2.9, is the
Court being asked to direct the filing of a Schedule of Distribution?       Yes 

 No

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Estate of

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Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties 
entitled and suggest(s) that the distributive shares of income and principal (residuary 
shares being stated in proportions, not amounts) are as follows:

Proposed Distributee(s)

Amount/Proportion

A.

Income:

B. Principal:

Proposed Distributee(s)

Amount/Proportion

Submitted By:   
(All petitioners must sign.  Place additional 
signatures on attachment if necessary):

Corporate Fiduciary (if applicable)

__________________________________________ 
Name of Corporate Fiduciary 

____________________________________________ 
Name of Petitioner

___________________________________________ 
Name of Representative and Title  

____________________________________________ 
Signature of Petitioner

___________________________________________ 
Signature of Officer/Representative 

____________________________________________
Name of Petitioner

____________________________________________ 
Signature of Petitioner

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Estate of 

, Principal 

(Verification must be by at least one petitioner.) 

Verification for Individual Petitioner 

The undersigned hereby verifies that  the  averment  of  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). 

________________________________ 
Date 

______________________________________ 
Signature of Petitioner

Verification for Corporate Petitioner

The  undersigned  hereby  verifies  that  he/she ____________________________  is
  title  __________________________________________ of the above-named 
name  of  corporation  _________________________________________________  and  that 
the  averment  of  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). 

_______________________________ 
Date

_____________________________________ 
Signature of Representative for 
Corporate Petitioner  

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. 

______________________________ 
Date

______________________________________ 
Signature of Counsel for Petitioner

Form OC-05  rev. 01.01.20 

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