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IN THE ORPHANS COURT DIVISION OF THE COURT OF

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					     IN THE ORPHANS’ COURT DIVISION OF THE COURT OF
       COMMON PLEAS OF WESTMORELAND COUNTY, PA



ESTATE OF                                   )
                                            )
                                            )                        No. 65-
                                            )
Deceased                                    )
                                            )
Late of                                     )                  TESTACY/INTESTACY




                      PETITION FOR DISTRIBUTION



TO THE HONORABLE, THE PRESIDING JUDGE OF SAID COURT:



          The petition of    respectfully represents:



   1. The decedent died on October 14, 2011, (in)testate, and at that time was

domiciled and resided in          /Westmoreland/PA
                             (municipality/county/state)


   2. Letters (testamentary) (of administration ) were granted on         , with bond.

   3. Letters were advertised in         and in the Westmoreland Law Journal, the first

complete advertisement having been made on           , more than four months before the

filing of the Account. Proofs of publication marked Exhibit “A” are attached.

   4. Within three months after the grant of letters written notice was sent to (the

following corporations and associations named as beneficiaries in the Will) and (the
Commonwealth or political subdivision having a claim for maintaining the decedent in an

institution where death occurred) (and) (each beneficiary named in the decedent’s Will)

(all the intestate heirs).

    5.      (a)      Decedent was married to         .

            (b)      The spouse survived the decedent on            .

            (c)      There is (no) (an) election by the surviving spouse. (Attach copy)

    6. The decedent did marry and no children were born to or lawfully adopted by the

decedent after the execution of the will or codicil (as follows):

    7. The family exemption of            was claimed by            (and the same has been set

aside.) (Attach exhibit)

    8. The estate is subject to Federal Estate Tax (and the same has been paid) (and a

closing letter has been received). (Attach copy)

    9. The estate is subject to Pennsylvania Inheritance Tax and the same has been paid

and a Notice of Inheritance Tax Appraisement has been received. (Attach copy)

    10. The estate is subject to Pennsylvania Estate tax (and the same has been paid) and

an Estate Tax Determination has been received. (Attach copy)

    11. Written notice has been given of the filing of the Account, as well as a copy of the

Account and of the time and date for audit to every unpaid creditor who has given written

notice of his claim to the petitioner or to the petitioner’s attorney of record. The

following is a list of all unpaid creditors, together with the amounts of their claims, the

category of claim under § 3392 of the PEF Code, and the extent to which their claims are

admitted:




                                               2
    Name and Address              Category of         Amount              Amount
                                    Claim                             Recommended for
                                                                         Allowance




   12. A charitable interest is (not) involved, (and notice was (not) given to the Attorney

General on        , under Rule 5.5 of the Pennsylvania Orphans’ Court Rules, and a

response has (not) been received.) (Attach a copy of response, if applicable.)

   13. The decedent was an inmate of a public institution (and a copy of the Account,

certified by counsel, has been filed with the Pennsylvania Department of Revenue in

accordance with Rule 6.7 of the Pennsylvania Orphans’ Court Rules).

   14. The decedent was a veteran or the child of a veteran entitled to benefits (and a

copy of the Account, certified by counsel, has been filed with the United States Veterans

Administration in accordance with Rule 6.8 of the Pennsylvania       Orphans’ Court

Rules).

   15. The decedent did receive medical assistance after August 15, 1994 (and the

Department of Public Welfare was given notice in accordance with the provisions of 62

Pa. C.S.A. § 1412).

   16. All parties, other than creditors, known to have an interest in the estate as unpaid

heirs or beneficiaries, have been given at least twenty days written notice of the   filing




                                             3
of the Account, as well as a copy of the Account and of the time and date or audit

(except as follows):

   17.       (a)       The following parties are not sui juris and are not represented:



             (b)       The following parties are in the military service of the United

                       States:

             (c)       Decedent at the time of death was known to be a fiduciary of the

                       following entities:



   18. There is no (partial) or (entire) intestacy. (Explain as necessary.)

   19. The names and addresses of all persons having any interest as devisees, legatees

or heirs, with the names of parents where necessary to show relationship, are as follows:

Name and Residence (Give name           Relationship          Sui Juris            Living
   of guardian, executor, or                                 (Yes or No)         (Yes or No)
     administrator, if any)




In the case of intestacy, where the decedent had a surviving spouse and surviving issue,

are all of such surviving issue also the issue of the surviving spouse? (Yes) (No)

   20. The following is a statement of all changes in distribution under the Will,

resulting from the death of persons named as beneficiaries therein, ademption of

specific gifts, election to take against the Will or otherwise, together with the date of

death of any such beneficiary:


                                              4
   21. Elections to take in kind are as follows: (Attach exhibits)

   22. No distribution has been made other than that appearing in the Account or in this

Petition, and receipts for all distributions are attached as Exhibit “       ”.

   23. All personal representatives are petitioners (except          who (has)(have) been

given written notice of the filing of the Account and the audit thereof, as set forth on

Exhibit “       ”).

   24. The following is a statement of the combined balance on hand as shown by the

Account, together with all additional receipts and disbursements not shown by the

Account: (Attach exhibits as appropriate)



Combined Balance on Hand, as shown by Account                            $



Additional assets not shown by Account:




Total corrected balance                                                  $



Additional disbursements not shown by Account:




Corrected net balance for distribution                                   $




                                               5
   25. The net balance for distribution consists of property of kind, form and character,

including as Exhibit “       ” a full description of real estate to be distributed, as follows:



Description of Personal Property                                       Value

                                                                       $




Real property (as described on Exhibit “          ”)



Total (corrected net balance for distribution)                         $



   26. Other matters requiring adjudication are as follows:




                                              6
            WHEREFORE, the petitioner(s) request(s) that a distribution be made by the

Court in accordance with the proposed Decree of Distribution submitted herewith.



                                                ____________________________________
                                                (Signature and Title)




                                          VERIFICATION


(I)(We), the undersigned petitioner, verify that the statements made in the foregoing

Petition are true and correct. (I) (We) understand that false statements which are made

herein are subject to penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to

authorities).



                                                ____________________________________
                                                (Signature and Title)




ESTADMDISTRIBUTION\PETITIONDISTRIBUTION




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