Petition For Settlement Of Small Estate (Date Of Death After 8-31-13) {1}

O.C. Form 1 Petition for Settlement of Small Estate (Rev. 10/04) In the Court of Common Pleas of York County, Pennsylvania Orphans' Court Division Estate of also known as , deceased : : : : : No. Petition for Settlement of Small Estate Pursuant to section 3102 of the Probate, Estates and Fiduciaries Code, the undersigned petitioner respectfully represents that: 1. The name and address of the petitioner are: 2. 3. The relationship of the petitioner to the decedent is: The decedent died on: 4. The decedent was domiciled at time of death in York County, Pennsylvania, with a last family or principal residence at: 5. The decedent's social security number is: 6. 7. The death certificate is attached hereto. The decedent died: (a) (b) intestate testate If the decedent died testate: 1 American LegalNet, Inc. www.FormsWorkFlow.com (i) the will has been probated, and a copy is attached hereto. Letters have been issued to: (ii) the will has not been probated and the original will is attached hereto. [If not attached, explain.] The personal representative(s) named therein is (are): 8. The name(s), relationship(s), and interest(s) of all parties beneficially interested in the estate are: Sui Juris (yes or no) Name Relationship Interest 9. A spouse's elective share: (a) (b) has not been claimed has been claimed. [Give details.] 10. If the decedent died testate, the decedent: (a) (b) was not married or divorced after the date of execution of the will was married or divorced after the date of execution of the will. [Give details.] 11. If the decedent died testate, the decedent: (a) did not have a child or children born or adopted after the date of execution of the will 2 American LegalNet, Inc. www.FormsWorkFlow.com (b) had a child or children born or adopted after the date of the execution of the will. [Give the name and date of birth or adoption of each such child.] Date of Birth or Adoption Name 12. The decedent died owning property (exclusive of real property and property payable under section 3101 of the Probate, Estates and Fiduciaries Code) of a gross value not exceeding $50,000, which is itemized below. [Include account numbers and registration numbers, etc. If a bequest is adeemed, explain.] Item Amount Total 13. An itemized statement of all claims against the estate is set forth below: (a) The following person(s) claim(s) the family exemption under section 3121 of the Probate, Estates and Fiduciaries Code by virtue of being a member of the same household as the decedent: Amount or Items Claimed Name Relationship Total 3 American LegalNet, Inc. www.FormsWorkFlow.com (b) Person Claiming Reimbursement The following persons claim reimbursement for debts, expenses, and other claims (including inheritance tax, if applicable) they have paid with their own funds: Nature of Date of Debt or Payment Payee Expense Amount Total (c) Claimant The following claims remain unpaid: Nature of Claim Amount Total 14. (a) (b) All claims are undisputed. The following claims are disputed: [Give details] 15. The petitioner has paid or will cause to be paid all Pennsylvania inheritance tax due on all property to be awarded under this petition. 16. All parties beneficially interested in the estate, other than the petitioner, including all holders of claims that are denied, or, in the case of an insolvent estate, all holders of claims who will not be paid in full, have: (a) (b) signed the joinder in this petition which is hereto attached; or been mailed at least ten (10) days written notice of the date, time, and place of the Orphans' Court audit session at which the petition will be ruled upon by the Court, a copy of which notice is attached hereto. 4 American LegalNet, Inc. www.FormsWorkFlow.com 17. Your petitioner proposes: (a) that the family exemption, if any, be paid or satisfied as follows: (b) that the following claims be paid: [Refer to section 3392 of the Probate, Estates and Fiduciaries Code to establish priority among claims, if necessary.] Nature of Claim Amount Claimant Total (c) the balance, if any, be distributed as follows: Item Amount Total Signature of Petitioner Typed Name: Signature of Attorney for Petitioner Typed Name: Supreme Court I.D. No.: Office Address: Telephone Number: 5 American LegalNet, Inc. www.FormsWorkFlow.com Verification The undersigned petitioner hereby verifies, subject to the penalties of 18 Pa. C.S.A. §4904 (relating to unsworn falsification to authorities), that the facts set forth in the foregoing petition which are within his (her) knowledge are true, and, as to the facts based on information received, after diligent inquiry, he (she) believes them to be true. Date: Signature of Petitioner Joinder I (we), the undersigned, being parties other than the petitioner beneficially interested in the estate of the foregoing decedent, do hereby certify that I (we) have read the foregoing petition and join in the prayer thereof. 6 American LegalNet, Inc. www.FormsWorkFlow.com Order And now, this day of , , upon consideration of the foregoing petition and on motion of the attorney for the petitioner, it is ordered that the petitioner distribute the property of the decedent under section 3102 (and section 3392, if applicable) of the Probate, Estate and Fiduciaries Code as follows: Name Amount Total This decree of distribution shall constitute sufficient authority to all transfer agents, registrars and others dealing with the property of the estate to recognize the persons named as entitled to receive such property without administration, and shall in all respects have the same effect as a decree of distribution after an accounting by a personal representative. By the Court, Judge 7 American LegalNet, Inc. www.FormsWorkFlow.com