GUARDIANSHIP OF INCAPACITATED PERSON

COURT OF COMMON PLEAS OF

ORPHANS' COURT DIVISION

ESTATE OF 

ACCOUNT OF

, AN INCAPACITATED PERSON , 

GUARDIAN

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 an incapacitated person.  If space is insufficient, riders may be 
attached.  Attach the papers required under items 2, 3, and 5, as applicable, and any 
additional decree or 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-03  rev. 01.01.20

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Estate of

, An Incapacitated Person

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

Petitioner:

 Petitioner:

Name:

Address:

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

2.

Judicial District or County issuing Adjudication of Incapacity:

 
________________________

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

3. A.  Explain the reason for filing this Account (if incapacitated person has died, state date

of death, name and address of personal representative and of his or her counsel, and     
attach a Short Certificate if available.  If incapacitated person has been adjudged to     
have regained capacity, state date of Decree and attach a copy.  If Account is filed for  
any other reason, state address of incapacitated person):

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 incapacitated person or the incapacitated

 person's estate and describe each in detail (if none, so state):

Form OC-03  rev. 01.01.20

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Estate of

, An Incapacitated Person

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 known 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-03  rev. 01.01.20

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Estate of

, An Incapacitated Person

6.

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

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

party's interest(s):

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).

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-03  rev. 01.01.20

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Estate of

, An Incapacitated Person

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-03  rev. 01.01.20

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Estate of 

, An Incapacitated Person 

(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 
certifies 
The  undersigned 
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. 

foregoing  Petition 

counsel  hereby 

that 

the 

______________________________ 
Date

______________________________________ 
Signature of Counsel for Petitioner

Form OC-03  rev. 01.01.20 

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