ESTATE OF 

, A MINOR

ACCOUNT OF ___________________________________________________, GUARDIAN

GUARDIANSHIP OF MINOR 

COURT OF COMMON PLEAS OF

 ORPHANS’ COURT DIVISION 

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 Guardian  of  the Estate of a minor or late minor.  If space is insufficient, 
riders may be attached.  Attach the papers required under items 2 and 5, 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-04  rev. 01-01-20 

Page 1 of 6 

Estate of

, A Minor

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

Petitioner:

   Petitioner:

Name:

Address:

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

2.

Judicial District or County Appointing Guardian:

_________________________

Date of Appointment as Guardian: 
Attach copy of Decree(s).

3. A.  Explain the reason for filing this Account (if minor has come of age, state date minor

 attained majority).

B .  Is this the first accounting for this estate? . . . . . . . . . . . . . . .       Yes      No

If not, identify prior accountings, the accounting periods covered, and the 
dates of adjudication of the prior accountings.

4. A.  Identify each unpaid claim against the minor or the minor's estate and describe in

detail (if none, so state):

Form OC-04  rev. 01-01-20

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Estate of

, A Minor

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

Petitioner(s) as to each question:

C. If guardian or attorney fees are being claimed, state amount and the period covered

for the requested fees:

5.

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 6 below.  In addition, notice of any 
unpaid claim not admitted, all questions requiring adjudication, and any requested 
fees 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.

C.

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.

Form OC-04  rev. 01.01.20

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Estate of

6.

List all parties of whom Petitioner(s) has/have notice or knowledge, having or 
claiming any interest in the estate, including the minor’s heirs at law.  This list 
shall:

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

interest(s):

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

Interest

, A Minor

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).

7.

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

Form OC-04  rev. 01.01.20

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Estate of

, A Minor

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

Form OC-04  rev. 01.01.20

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Estate of 

, A Minor

(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 
above-named 
________________________________________  of 
_________________________________________________  and 
corporation 
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). 

name 
that 

the 

__________________________________ 
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-04  rev. 01.01.20 

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