INCAPACITATED ADULT INFORMATION FORM Commonwealth of Virginia VA. CODE §§ 64.2-2011, 64.2-2013, 64.2-2016 Court File No. ................................................................. [For appointment of guardian, conservator, committee, or trustee for ex-service person] Circuit Court of ............................................................................................................................................................................................................................ 1. 2. 3. 4. 5. 6. 7. 8. 9. Incapacitated person's full name ................................................................................................................................................................................. ........................................................................................................................................................................ Residence address (street, city, state) Date of birth .................................................................................................................................................................................................................................................... .............................. Place of birth ................................................. [ ] Married [ ] Widowed [ ] Single [ ] Divorced Qualification requested: [ ] guardian [ ] conservator [ ] limited conservator [ ] trustee for ex-service person [ ] committee [ ] standby guardian [ ] standby conservator Court's order entered on Day telephone .................................................................................... , and recorded in ....................................................................... Name of person qualifying ............................................................................................................................................................................................. ............................................................................................ Night telephone .................................................................................. Street address ....................................................................................................................................................................................................................... Mailing address, if different .......................................................................................................................................................................................... ................................................................................................................................................................................. 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. ............................................... DATE ................................................................................................ PRINTED NAME OF PERSON SEEKING QUALIFICATION _______________________________________________ SIGNATURE OF PERSON SEEKING QUALIFICATION ............................................... DATE ................................................................................................ PRINTED NAME OF PERSON SEEKING QUALIFICATION _______________________________________________ SIGNATURE OF PERSON SEEKING QUALIFICATION FORM CC-1652 MASTER 10/12 American LegalNet, Inc. www.FormsWorkFlow.com