INCAPACITATED ADULT INFORMATION FORM

Clear All Data
INCAPACITATED ADULT INFORMATION FORM
Court File No.
.................................................................
Commonwealth of Virginia
VA. CODE §§ 64.2-2011, 64.2-2013, 64.2-2016
[For appointment of guardian, conservator, committee, or trustee for ex-service person]
Circuit Court of ............................................................................................................................................................................................................................
1.
Incapacitated person’s full name
2.
Residence address (street, city, state)
.................................................................................................................................................................................
........................................................................................................................................................................
....................................................................................................................................................................................................................................................
3.
Date of birth
4.
Qualification requested: [ ] guardian [ ] conservator [ ] limited conservator [ ] trustee for ex-service person
[ ] committee [ ] standby guardian [ ] standby conservator
5.
Court’s order entered on
6.
Name of person qualifying .............................................................................................................................................................................................
7.
Day telephone
8.
Street address .......................................................................................................................................................................................................................
9.
Mailing address, if different
..............................
Place of birth
....................................................................................
............................................................................................
[ ] Married [ ] Widowed [ ] Single [ ] Divorced
, and recorded in
Night telephone
.......................................................................
..................................................................................
..........................................................................................................................................................................................
10. Name of other person qualifying
11. Day telephone
.................................................
.................................................................................................................................................................................
............................................................................................
Night telephone
..................................................................................
12. Street address .......................................................................................................................................................................................................................
13. Mailing address, if different
..........................................................................................................................................................................................
14. Name of assisting attorney, if any ..................................................................................... Telephone
15. Attorney’s mailing address
...............................................................
............................................................................................................................................................................................
I hereby certify that to the best of my knowledge and belief this is an accurate statement of facts, and I acknowledge a
continuing legal duty to report any later discovered errors or inconsistencies to the Clerk of Court.
.....................................................
DATE
.......................................................................................
_____________________________________________
PRINTED NAME OF REQUESTING PERSON
SIGNATURE OF REQUESTING PERSON
INFORMATION TO BE FURNISHED BY EACH PERSON SEEKING QUALIFICATION
16. Have you ever been convicted of a felony? [ ] yes [ ] no. (If yes, explain the details on a separate sheet of paper.)
17. Have you ever filed for bankruptcy? [ ] yes [ ] no. (If yes, explain the details on a separate sheet of paper.)
18. Are you now, or have you ever been, an attorney at law in Virginia or elsewhere? [ ] yes [ ] no. (If yes, and you do not
now possess an active license form the Virginia State Bar, explain the details on a separate sheet of paper.)
19. The value of the incapacitated person’s personal property (see instructions) is
$
.................................................
The value of the incapacitated person’s real estate (see instructions) is
$
.................................................
The total value of the incapacitated person’s entire estate (see instructions) is
$
.................................................
I (we) hereby certify that to the best of my (our) knowledge and belief this is an accurate statement of facts, and I (we)
acknowledge a continuing duty to report any later discovered errors or inconsistencies to the Clerk of Court.
...............................................
................................................................................................
_______________________________________________
PRINTED NAME OF PERSON SEEKING QUALIFICATION
SIGNATURE OF PERSON SEEKING QUALIFICATION
...............................................
................................................................................................
_______________________________________________
DATE
PRINTED NAME OF PERSON SEEKING QUALIFICATION
SIGNATURE OF PERSON SEEKING QUALIFICATION
DATE
FORM CC-1652 MASTER 10/12