ACCOUNT FOR INCAPACITATED ADULT COMMONWEALTH OF VIRGINIA VA. CODE §§ 64.2-1206, 64.2-1308, 64.2-1305 Court File No. ............................................................ Circuit Court of ................................................................................................................................................................................................................................ Estate of .............................................................................................................................................................................................. , an incapacitated adult Residence of incapacitated person: .......................................................................................................................................................................................... Type of Fiduciary: [ ] Conservator [ ] Guardian [ ] Committee [ ] Trustee for ex-service person [ ] Limited Conservator .................................................................... Name of fiduciary ....................................................................................................................... Day telephone Mailing address ............................................................................................................................................................................................................................... ........................................................................................................... Day Name of other fiduciary Mailing address telephone .................................................................... ............................................................................................................................................................................................................................... This is account number From [ ] one [ ] two [ ] three [ ] ........................................ Is this a final account? [ ] yes [ ] no. ............................................. (date of qualification or end of last account) to .......................................... (end of this account) ACCOUNT SUMMARY 1. Beginning Assets (from Parts 1, 2 and 5 of the inventory or from the prior account) 2. Receipts* 3. Gains on Asset Sales (attach itemized list) 4. Adjustments (attach itemized list) 5. Total of 1, 2, 3 and 4 (must equal Total on Line 10) .................................................................. .................................................................. .................................................................. $ .................................................................. $ .................................................................. _________________________________________ 6. Disbursements (attach itemized list) 7. Losses on Asset Sales (attach itemized list) 8. Distributions (final account only) (attach itemized list) 9. Assets on Hand (attach itemized list) (carrying value) 10. Total of 6, 7, 8 and 9 (must equal Total on Line 5) $ .................................................................. .................................................................. .................................................................. .................................................................. $ .................................................................. _________________________________________ * Any amounts received as Designated Representative but not included in 2 above (see Va. Code § 64.2-1312). $ ** Market Value of Assets on Hand $ .................................................. .................................................. I (We) certify that this is a true and accurate accounting of the assets of this estate for the period described and that to the best of my/our knowledge all taxes have been paid or provided for. Date Date ............................................................. ............................................................. Fiduciary's signature ____________________________________________ Fiduciary's signature ____________________________________________ NOTE: Virginia law requires that every account be signed by all fiduciaries. FORM CC-1682 MASTER 10/12 American LegalNet, Inc. www.FormsWorkFlow.com