INVENTORY FOR DECEDENT222S ESTATE Court File No. ........................................................................... COMMONWEALTH OF VIRGINIA VA. CODE 247247 64.2-1300, 64.2-1308 Circuit Court of .......................................................................................................................................................................................................................... Decedent222s name Fiduciary(ies) name(s)............................................................................................................................................................................................................. Date of fiduciary(s) qualification ............................................................................ Date of decedent222s death ...................................................This is [ ] the first inventory [ ] an inventory showing after discovered assets [ ] an amended inventory restating all assets. The fiduciary filing this inventory is [ ] an administrator [ ] an executor [ ] a curator. Total value of assets listed in Parts 1 and 3 (estate for bond) .................................................................... $ ............................................... otal value of assets listed in Parts 1, 3, and 4 (estate for probate tax) ................................................. $ ............................................... T ATTACH ADDITIONAL SHEETS IF NEEDED Part 1. The decedent222s personal estate under your supervision and control, valued at the date of death. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 1: Page 1 of 4 FORM CC-1670 MASTER 10/12 Part 2. The decedent222s interest in multiple party accounts and multiple party certificates of deposit in banks and credit unions, valued at the date of death. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 2: Part 3. The decedent222s real estate in Virginia over which you have a power of sale, valued at the date of death. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 3: Part 4. The decedent222s other real estate in Virginia, valued at the date of death. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 4: Page 2 of 4 FORM CC-1670 (MASTER) 10/12 Part 5. The decedent222s non-Virginia real estate, valued at the date of death. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 5: CERTIFICATE OF ACCURACY, COMPLETENESS, AND MAILING [Must be signed by each fiduciary.] 1. I (we) hereby certify and affirm under penalty of law, that to be best of my (our) knowledge and belief this is an accurate and complete inventory of this estate made in accordance with my (our) responsibilities under Virginia law. 2. I (we) hereby also certify and affirm that (choose one): A. [ ] On or before the date of filing this Inventory with the Commissioner of Accounts, I (we) sent a copy of it by first class mail to every person entitled to a copy, pursuant to Va. Code Section 26-12.4, who made a written request therefore. The names and addresses of the persons to whom copies were sent and the dates they were mailed are shown on page 4. or B. [ ] No person entitled to a copy of this Inventory pursuant to Virginia Code Section 26-12.4 made a written request therefore. Date ............................................................. SIGNATURE OF FIDUCIARY Address .......................................................................................................................... Telephone No. ............................................................................................................. Date ............................................................. SIGNATURE OF FIDUCIARY Address: ......................................................................................................................... Telephone No. ............................................................................................................. Date ............................................................. SIGNATURE OF FIDUCIARY Address .......................................................................................................................... Telephone No. ............................................................................................................. CERTIFICATE OF COMMISSIONER The Commissioner of Accounts has not independently verified the value of the items on the inventory, or the fact that they are the only assets of the estate. Inspected, found to be in proper form, and approved on ........................................................................................................................................ COMMISSIONER OF ACCOUNTS Received in the Clerk222s Office and admitted to record on ..................................................................................................................................... [ ] CLERK [ ] DEPUTY CLERK Page 3 of 4 FORM CC-1670 (MASTER) 10/12 Certificate of Mailing I, the undersigned, do hereby certify that I have mailed a copy of the foregoing INVENTORY FOR DECEDENT222S ESTATE to the following individuals on this the .............................. day of ................................................................................, 20 .................... . EXECUTOR/ADMINISTRATOR EXECUTOR/ADMINISTRATOR EXECUTOR/ADMINISTRATOR Name of Recipient Name of Recipient Address Address City State ZIP City State ZIP Name of Recipient Name of Recipient Address Address City State ZIP City State ZIP Name of Recipient Name of Recipient Address Address City State ZIP City State ZIP Page 4 of 4 FORM CC-1670 (MASTER) 10/12