Tio. Cnty. Pa. 17CR9756 app II
IN THE MATTER OF | : IN THE COURT OF COMMON PLEAS |
THE ESTATE | : OF TIOGA COUNTY, PENNSYLVANIA |
OF | : ORPHANS' COURT DIVISION |
DECEASED. | : NO 20 _____ |
STATEMENT OF PROPOSED DISTRIBUTION
The statement of ______________________ (Fiduciary) respectfully represents:
1. The decedent, _________________ , died testate (or intestate) on _____________________ , a resident of the _______________________ of __________________ , Tioga county, Pennsylvania.
2. Decedent's Last Will and Testament, dated _________________ , was duly admitted to probate by the Register of Wills of Tioga County, Pennsylvania on ________________ , 20___, and _______________________ was appointed Executor (or Letters of Administration were duly issued by the Register of Wills of Tioga County, Pennsylvania on _______________ , 20___, to ___________________ .
3. The decedent, was survived by
(a) (State whether a husband or wife survived, and if so, his or her name and residence; whether he or she has elected to take under or against the will, and, if so, whether the election has been duly recorded and filed, and furnish a copy; and whether or not the decedent left issue or adopted children, and their names and residences, when material).
(b) The names and residences of all beneficiaries, their relationship to the decedent, and the amount and nature, and character of their interest (noting such devises and bequests as have been revoked, adeemed, lapsed, assigned or disclaimed) and the supporting information relative thereto are as follows:
(In cases of partial intestacy, state the names and residences of the heirs and next of kin, their relationship to the decedent, and, where applicable, the names of their parents, thereby disclosing the relationships and interests derived therefrom).
________________________________________________________________________
________________________________________________________________________
Name and Residence | Relationship | Amount, Natural and Characteristic if Interest |
4. All of said parties in interest are living of full age, and sui juris except:
(State exceptions, if any, as to those parties in interest who are under legal disability, specifying the reason therefore, and the names and residence of their guardians or committees and how appointed (specifying the Court, term and number, where applicable); the date of the deaths of any of the beneficiaries who are deceased, the names and residences of their personal representatives, and the date and places of the grant of their letter, or the names and residences of their issue, when material. If there no exceptions, insert the work "none").
5. All parties in interest, including unpaid creditors and claimants, and any parties with arguable interests.
(a) Have had notice of the filing of the account, the statement of proposed distribution and of the time and place of audit by:
(State method, date and exceptions, if any. In those instances, where notice has been given, a copy of said notice as well as the names and addresses of the parties notified, shall be appended to the statement of proposed distribution. In those instances where notice is yet to be given, a copy of said notice, as well as the names and addresses of the parties notified, shall be filed with the Court at the time and place of audit together with a certificate of notice executed by counsel). (Strike out subsection (1) or (2), whichever is inapplicable).
(b) Shall be givennotice of the filing of the account, the statement of proposed distribution and of the time and place of audit as required by the Rule of Court.
6. The decedent did not marry after the execution of the will and codicils (if any) and there were _________ children born to or adopted by the decedent thereafter.
(Insert the names of any after-born or adopted children and dates of birth or adoption. In either case, state the names and residences of the spouse and children).
7. Charitable bequests are/are not involved:
(Proof of service pursuant to Supreme Court O.C.R.).
8. Pennsylvania Transfer Inheritance and Estate Tax are paid in full. Notice of the filing of Appraisement by the Pennsylvania Department of Revenue was filed in the Office of the Register of Wills of Tioga County, Pennsylvania on ____________ , 20___, appraising the estate at $ __________ . The Register of Wills allowed debts and deductions of $ ___________________ , making a taxable estate for __________ Inheritance Tax purposes of $ _______________ . Inheritance Tax at the rate of ___________ ( %) per cent, amounted to $ _________________ . The dates and amounts of payments thereon, are as follows:
Date of Payment Payment + Credit Total Payment and Credit
9. The names and addresses of unpaid creditors from whom the accountant has received written notice, the amount of their claims, and whether or not such claims are admitted to be correct, as well as the names of any other unpaid claimants of whom the accountant has notice or knowledge, are as follows:
(If too many for the space annex a list thereof; if no such claim, insert the word "none").
10. The decedent was ____________ , at the time of death, a fiduciary in another estate which has not been terminated by a final adjudication or in writing by receipt and release, agreement or other form of written release.
(If so, state the present status thereof and the Court, term and number thereof, if any).
11. No share of any beneficiary has been assigned or attached, except:
(If none, so state "none").
12. The estate is/is not subject to Federal Estate Tax. A Federal Estate Tax Closing Letter has/has not been received dated ______________ .
13. State of Facts relating to proposed distribution:
(The Accountant should recite the material facts and material parts of the will (or Intestate Laws) which govern the distribution of the assets of the Fiduciary).
14. The following are questions which require adjudication by the Court:
(Frame issues such as in a pleading in the form of questions which the Court must answer in order to determine the proper distribution of the assets. Also indicate after each question the Accountant's interpretation of any dispute or fairly disputable question. If there are no questions which require adjudication by the Court, so state).
15. An itemization of additional charges and/or credits sought to be included in the adjudication for receipts or disbursements not set forth in the account is as follows:
(If none, insert the word "none". With the exception of filing fees and credits of a minor nature, credits not set forth herein shall not be considered or approved by the Court, including, but not limited to commissions, and/or fees of fiduciaries or their counsel, unless written notice thereof has been given to all parties in interest, at least ten (10) days prior to the date of audit, in which event the same shall be set forth on the appearance slip of the attorney for the accountant, and further, in such event, copies of the aforesaid written notice shall be submitted with the appearance slip of the attorney for the accountant, and further, in such event, copies of the aforesaid written notice shall be submitted with the appearance slip for the attorney for the accountant).
16. A reserve is/is not requested,
(Strike out the inapplicable word or words. If a reserve is requested, state the amount and purpose thereof).
WHEREOF, we propose to distribute the assets as follow:
Name of Distributee | Account Value | Fair Market Value |
______________________ | ______________________ | |
TOTAL DISTRIBUTION | ______________________ | ______________________ |
______________________ | ______________________ | |
___________________________________ Accountant |
COMMONWEALTH OF PENNSYLVANIA | : |
:SS | |
COUNTY OF TIOGA | : |
_____________________ , the within names petitioner(s) being duly sworn, depose(s) and say(s) that the facts set forth in the foregoing petition which are within the affirmed/personal knowledge of the petitioner(s) are true, and as to facts based on the information of other, the petitioner(s), after diligent inquiry, believe(s) them to be true.
__________________________________________
Signature(s) of Individual Petitioner(s)
Sworn to and subscribed before me
This ___________ day of _____________ , 20____
COMMONWEALTH OF PENNSYLVANIA | : |
:SS | |
COUNTY OF TIOGA | : |
________________________________ , being duly sworn according to law, dispose and says that he is the ____________________ of the above names ____________________ and that the facts set forth in the foregoing petition which are within the personal knowledge of the deponent are true, and as to facts based on the information of others, the deponent, after diligent inquiry, believes them to be true.
__________________________________________
Signature of Officer of Corporate Petitioner
Sworn to and subscribed before me
This ___________ day of _____________ , 20____
Tio. Cnty. Pa. 17CR9756 app II