INVENTORY FOR ESTATE OF INCAPACITATED ADULT COMMONWEALTH OF VIRGINIA VA. CODE §§ 64.2-1300, 64.2-1308, 64.2-2016, 64.2-2024 Court File No. ............................................................................................. Circuit Court of .......................................................................................................................................................................................................................... Incapacitated person's name ................................................................................................................................................................................................ Fiduciary(ies) name(s) ............................................................................................................................................................................................................ Date of qualification of fiduciary(ies) .............................................................................................................................................................................. This is [ ] the first inventory [ ] an inventory showing after discovered assets [ ] an amended inventory restating all assets. The fiduciary filing this inventory is [ ] a conservator [ ] trustee for ex-service person [ ] committee for an incarcerated person [ ] limited conservator Total value of assets listed in Parts 1, 2, 5 and 8 (for bond purposes) .......................................................... $ .............................................. ATTACH ADDITIONAL SHEETS IF NEEDED Part 1. The incapacitated person's personal estate under your supervision and control. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 1: FORM CC-1671 (MASTER, PAGE ONE OF THREE) 10/12 American LegalNet, Inc. www.FormsWorkFlow.com Part 2. The incapacitated person'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 incapacitated person's other real estate in Virginia. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 3: Part 4. The incapacitated person's other non-Virginia real estate. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 4: Part 5. The incapacitated person's interest in any real or personal property that will pass to another at the incapacitated person's death by way of survivorship or beneficiary designation. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 5: FORM CC-1671 (MASTER, PAGE TWO OF THREE) 11/06 American LegalNet, Inc. www.FormsWorkFlow.com Part 6. The incapacitated person's interest in any trust. DESCRIPTION OF PROPERTY VALUE TOTAL VALUE OF PART 6: Part 7. The incapacitated person's rights to periodic payments from certain agencies of the U.S. government. DESCRIPTION OF PROPERTY TOTAL ANNUAL VALUE TOTAL VALUE OF PART 7: Part 8. The incapacitated person's right to periodic payments from any other source. DESCRIPTION OF PROPERTY TOTAL ANNUAL VALUE TOTAL VALUE OF PART 8: 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 FORM CC-1671 (MASTER, PAGE THREE OF THREE) 11/06 American LegalNet, Inc. www.FormsWorkFlow.com