Using This Form

Form CC-1612
REAL ESTATE AFFIDAVIT
Form CC-1612
Using This Revisable PDF Form
1. Copies
a. Original – to court.
2. Prepared by
a. Data Element Nos. 15 through 24 are completed by clerk.
b. Data Element Nos. 1 through 14 are completed by subscriber.
3. Attachments
Affidavit of subscriber stating that he has made diligent inquiry into the names, addresses
and ages of heirs of decedent.
4. Preparation details – none.
OFFICE OF THE EXECUTIVE SECRETARY
SUPREME COURT OF VIRGINIA
CC-1612 Revised 05/10
REAL ESTATE AFFIDAVIT
COMMONWEALTH OF VIRGINIA
Court File No.
1
....................................................................
VA. CODE § 64.2-510
2
.................................................................................................................................................................................................................................
3
Circuit Court
4
................................................................................................................................................
.......................................................................
NAME OF DECEDENT
DATE OF DEATH
5
.............................................................................................................................................................................................................................................................
NAME AND ADDRESS OF SUBSCRIBER
.............................................................................................................................................................................................................................................................
6
in the real property of the decedent; AND/OR
[ ] I have an interest as .............................................................................................................
7
as
[ ] I qualified in ....................................................................................................................................................................................................................
NAME OF COURT
the personal representative of the above-named decedent, who died intestate as to the real estate described herein, and
who, at the time of death, was seized of real property in this county/city, briefly described as
8
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
The name and last known address of decedent’s heirs are:
NAMES OF HEIRS
ADDRESSES
9
RELATIONSHIP
AGE
11
12
10
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.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
.............................................................................................................................................................................................................................................................
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13
_____________________________________________________
DATE
SIGNATURE OF SUBSCRIBER
14
15
State/Commonwealth of ......................................................................
16
[ ] City [ ] County of ............................................................................
Subscribed and sworn to before me
by
17
.......................................................................................................................................................................................................................................................
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PRINT NAME OF SIGNATORY
this ........................... day of ............................................................................................. , 20
........................
.
19
_____________________________________________________
[ ] CLERK [ ] DEPUTY CLERK [ ] NOTARY PUBLIC
20
21
Registration No. ................................................................
My commission expires
22 Circuit Court this
VIRGINIA: In the Clerk’s Office of the ...................
the foregoing AFFIDAVIT was filed and admitted to record.
23
......................
Teste:
day of
.................................................
..................................................... ,
20
...........
24
______________________________________________
CLERK
By:
FORM CC-1612 MASTER 05/10
25
__________________________________ ,
Deputy Clerk
Form CC-1612
REAL ESTATE AFFIDAVIT
Form CC-1612
Data Elements
1. Court file number assigned by clerk’s office.
2. Court name.
3. Name of decedent.
4. Date of decedent’s death.
5. Name and address of subscriber.
6. Check box and enter description of interest (e.g. “heir at law”).
7. Check box and enter name of court in which person qualified if filing is a list of heirs.
8. Brief description of property of decedent. List book and page number, if known.
9. Name(s) of last known heir(s) of decedent.
10. Address(es) of last known heirs of decedent.
11. Relationship of last known heirs of decedent.
12. Age, if known, of last known heirs of decedent.
13. Date signed by subscriber.
14. Signature of subscriber.
15. State in which signature is acknowledged.
16. City or county in which signature is acknowledged.
17. Name of subscriber.
18. Date form acknowledged and sworn to before the clerk, deputy clerk or notary.
19. Signature of clerk if acknowledged by clerk. If acknowledged by deputy clerk, print or
type the clerk’s name.
20. Date commission expires if acknowledged by a notary.
21. Registration number if acknowledged by notary.
22. Name of court.
23. Date on which Affidavit admitted to record.
24. Signature of clerk if filed with clerk. If filed with deputy clerk, print or type the clerk’s
name.
25. Signature of deputy clerk if filed with deputy clerk.
OFFICE OF THE EXECUTIVE SECRETARY
SUPREME COURT OF VIRGINIA
CC-1612 Revised 05/10