York Cnty. C.P. Local Rules of Orphans' Court Procedure Rule 5.16

(a) A petition to compromise and settle a wrongful death and survival action shall contain

the following averments of fact:

(1) The name, age, residence, and date of death of the decedent and whether the

decedent died testate or intestate;

(2) The name of the personal representative, the date of the personal

representative’s appointment, that letters were granted and duly advertised, and the

amount of bond, if any;

(3) The occupation of the decedent at the time of the decedent’s death, the salary

and average earnings, the name of decedent’s employer and address if the

decedent was not self-employed;

(4) The names and addresses of all heirs or next of kin, stating whether they are

dependent upon the decedent and whether they are sui juris, with the names of their

guardians, if any;

(5) The names and addresses of all creditors who have or had claims against the

estate, whether or not they have been paid, and if paid, by whom;

(6) A summary of the facts of the case, including the date of accident or injury and

circumstances surrounding the accident or injury; if the case involves an automobile

accident, the accident report should be attached as an exhibit to the petition;

(7) A statement of the reasonableness of the proposed compromise or settlement;

(8) A specific list of costs sought to be reimbursed from the gross settlement,

including proposed apportionment between the survival action and wrongful death

action, and amount of counsel fees to be paid, if any; and

(9) A statement that notice of the presentation of the petition has been given to all

beneficiaries named under the decedent’s will, if the decedent died intestate, and to

the decedent’s intestate heirs, whether the decedent died testate or intestate.

(b) The following exhibits shall be attached to the petition:

(1) A copy of any documents which support the averments made under (a)(1), (2),

(3), (5), or (6) above;

(2) A letter or other verification from Department of Revenue indicating no objection

to the proposed distribution between the survival and wrongful death actions;

(3) A letter or other verification from the Department of Human Services or any

other subrogation lienholder indicating that there is no Medicare or other lien, or

confirmation of the amount of the lien that will be paid under the proposed

distribution;

(4) An affidavit of service of notice on all potential beneficiaries and creditors as

named in the petition under (a)(4), (5), or (9) above;

(5) The joinder of all parties who consent and;

(6) A proposed order approving the settlement.

(c) The Petition may be decided by the Court pursuant to Pa.R.Civ.P. 208.4.