INVENTORY FOR ESTATE OF A MINOR COMMONWEALTH OF VIRGINIA VA. CODE §§ 64.2-1300, 64.2-1308, 64.2-1701, 64.2-1702, 64.2-1706 Court File No. ........................................................................... Circuit Court of .......................................................................................................................................................................................................................... Minor's name........................................................................................................... Date of birth ............................................................................... Fiduciary's name ....................................................................................................................................................................................................................... Date of fiduciary's qualification ......................................................................................................................................................................................... This is [ ] the first inventory [ ] an inventory showing after discovered assets [ ] an amended inventory restating all assets. The fiduciary filing this inventory is [ ] a guardian [ ] a temporary guardian [ ] trustee under Court Order (structured settlement) Total value of assets listed in Parts 1, 2, and 7 ATTACH ADDITIONAL SHEETS IF NEEDED Part 1. The minor's personal estate under your supervision and control. DESCRIPTION OF PROPERTY VALUE $ ............................................... TOTAL VALUE OF PART 1: (Page 1 of 3) FORM CC-1672 MASTER 10/12 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. The minor's real estate in Virginia over which you have a power of sale. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 2: Part 3. The minor's other real estate in Virginia. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 3: Part 4. The minor's non-Virginia real estate. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 4: Part 5. The minor's legal or equitable ownership interest in any real or personal property that will pass to another at the minor's death by means other than testate or intestate succession. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 5: (Page 2 of 3) FORM CC-1672 MASTER 7/99 American LegalNet, Inc. www.FormsWorkFlow.com Part 6. The minor's rights to periodic payments from any agency of the U. S. government. DESCRIPTION OF PROPERTY TOTAL ANNUAL VALUE TOTAL VALUE OF PART 6: Part 7. The minor's rights to periodic payments from any other source. DESCRIPTION OF PROPERTY TOTAL ANNUAL VALUE TOTAL VALUE OF PART 7: CERTIFICATE OF ACCURACY AND COMPLETENESS [Must be signed by each fiduciary.] I (we) hereby certify that to the 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. Date ...................................................................... Fiduciary ______________________________________________________ Address .............................................................................................................................................. Telephone No.: ................................................................................................................................ Date ...................................................................... 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 Clerk's Office and admitted to record on ....................................................................................................................................... _______________________________________________________ Clerk (Page 3 of 3) FORM CC-1672 MASTER 7/99 American LegalNet, Inc. www.FormsWorkFlow.com