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  rev 01.01.20

Page 1 of 11 

Estate of 

, Deceased 

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

Petitioner:

Petitioner:

Name:___________________________________________ 

___________________________________________________ 

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: 

     

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. 

No

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.

2. Decedent died on

.

Letters Testamentary or         Letters of Administration were granted to Petitioner(s) on 

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? . . .      Yes 
Dates of advertising of the grant of  Letters: 

   No 

Form OC-01  rev. 01.01.20 

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Estate of 

, Deceased 

3. Was decedent survived by a spouse? . . . . . . . . . . . . . . . . . . . . . . .        Yes         No 

If yes, name of the surviving spouse: 

4. Has the surviving spouse filed to take an elective share? .  .        Yes       No

N/A

(see 20 Pa.C.S. §§ 2201 et seq.)

 If yes, attach a copy of the election and state date of election: 

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)?  . . . . . . . . .    Yes       

  No

N/A

Were any children born to decedent after execution of 
Will or Codicil(s)?  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

            Yes      No      N/A

If yes, give names and dates of birth: 

Name: 

Date of Birth: 

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  rev. 01.01.20 

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Estate of 

, Deceased 

8. 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 the estate as beneficiaries under the Will (if
beneficiary is a trust, name the trust and trustee as the Interested Party) or Codicil(s) or as
interstate heirs if there is a complete or partial intestacy.  This list Shall:

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

interest(s):

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

Interest

Form OC-01  rev. 01.01.20 

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Estate of 

, Deceased 

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

Interest

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).

Form OC-01  rev. 01.01.20 

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Estate of 

, Deceased 

D. If distribution is to be made to the personal representative of a deceased
party, state date of death, date and place of grant of Letters and type of
Letters granted.

10. Other than the claim for the family exemption, list the names of all known claimants and

the amount of their claims and state whether each claim is admitted.

Name and Address of Each Claimant

Amount of Claim

Claim 
Admitted?

Will Claim 
Be Paid In 
Full?

Yes    

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

No 

Yes 

No 

If the estate is insolvent, attach a schedule setting forth the order of 
preference under 20 Pa.C.S. § 3392 and the proposed payments. 

Form OC-01  rev. 01.01.20 

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Estate of 

, Deceased 

11. Was family exemption claimed?    ...............................................

Yes

No

Was family exemption allowed?  ............................................... 

Yes

No

Family exemption claimant’s name and relationship: 

Name: 

Relationship:  

12.

The amount of Pennsylvania Transfer Inheritance Tax paid, the date(s) of payment(s), and
the interest(s) upon which paid, are as follows:

Date 

Payment 

Interest 

13. On the date of death, was the decedent a fiduciary

(personal representative, trustee, guardian, agent under power
of attorney) or surety on the bond of a fiduciary?  . . . . . . . . . . . . . . 

Yes

  No

If yes, provide the name of the estate, indicate whether an Account has been 
filed  and  confirmed  and  all  awards  performed,  or, 
the  alternative, 
how 
the  decedent’s  estate  will  be  discharged  for  the  decedent’s  fiduciary 
administration of the estate. 

in 

Form OC-01  rev. 01.01.20 

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Estate of 

, Deceased 

14. On the date of death, was the decedent a party (as a

plaintiff or defendant) in any litigation?  . . . . . . . . . . . . . . . . . . . . . . . . 

Yes

   N  o   

If yes, provide the caption of the litigation, docket number, where the 
matter is currently pending, and its status. 

15. A.  Describe in detail any questions requiring adjudication and state the position of the

      Petitioner(s) as to each question:

B. Has notice of the question requiring adjudication been given

to the parties identified in Paragraph 9 above?   . . . . . . . . . . .    Yes 

No 

16.

If Petitioner(s) has/have knowledge that a share has been assigned, renounced,
disclaimed, or attached, provide a copy of the assignment, renunciation, disclaimer, or
attachment, together with any relevant supporting documentation and list the attached
documents below.

Form OC-01  rev. 01.01.20

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Estate of 

, Deceased 

17. Had the decedent been adjudicated an incapacitated person?

  Yes     No

If yes, attach a copy of the Order if available; otherwise state the Court, 
docket number, date, and name of Hearing Judge. 

18. A.  List or attach a separate list of additional receipts and disbursements since the closing

date of the Account.

B. Has notice of the additional receipts and disbursements been

given to the parties identified in Paragraph 9 above? . . . . .  

Yes

No

19.

If a reserve is requested, state amount and purpose.

Amount: 

Purpose: 

If a reserve is requested for counsel fees, has notice of the 
amount of fees to be paid from the reserve been given to the 
interested parties ?  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      Yes          No
If so, attach a copy of the notice. 

Form OC-01  rev. 01.01.20 

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Estate of 

, Deceased 

20.

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 

As to real estate only?  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

 Yes         No

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: 

A. Income:

Proposed Distributee(s)

Amount/Proportion 

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

Form OC-01  rev. 01.01.20 

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Estate of 

, Deceased 

(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 

for 
The  undersigned  counsel  hereby  certifies 
that 
Adjudication/  Statement  of  Proposed  Distribution 
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. 

foregoing  Petition 

the 
is  a 

___________________________ 
Date

__________________________________________ 
Signature of Counsel for Petitioner

Form OC-01  rev. 01.01.20 

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