PROBATE INFORMATION FORM Court File No.: COMMONWEALTH OF VIRGINIA (For appointment of executor, administrator, curator, and/or probate of a will without qualification.) Circuit Court of 1. Decedents full name [ ] Married [ ] Single [ ] Divorced [ ] Widowed 2. Decedents Residence address at death (street, city, state) 3. Date of birth Date and place of death 4. Proof of death: [ ] Death certificate [ ] Obituary [ ] Ot her (specify) 5. The decedent died: [ ] with a will [ ] without a will. Date of w ill (and codicils) 6. Requested action: appointment of [ ] administrator [ ] executor [ ] curator [ ] probate of will 7. Name of person making request 8. Mailing address 9. Basis for request: [ ] executor named in will [ ] sole distributee [ ] other distributee [ ] creditor [ ] other 10. Name of person seeking appointment 11. Day telephone Night telephone 12. Residence address 13. Mailing address, if different 14. Name of any additional person seeking appointment 15. Day telephone Night telephone 16. Residence address 17. Mailing address, if different 18. Name of assisting attorney, if any Telephone 19. Attorneys mailing address 20. The total value of the decedents real and personal estate [ ] did [ ] did not exceed $15,000 on the date of death. 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 inconsist encies to the Clerk of Court. DATE PRINTED NAME OF REQUESTING PERSON SIGNATURE OF REQUESTING PERSON INFORMATION TO BE FURNISHED BY EACH PERSON SEEKING APPOINTMENT 21. Are you a person under a disability? [ ] yes [ ] no. (See Instruc tions for explanation.) 22. Have you ever been convicted of a felony? [ ] yes [ ] no. 23. Have you ever filed for bankruptcy? [ ] yes [ ] no. 24. Are you now, or have you ever been, an attorney at law in Virginia o r elsewhere? [ ] yes [ ] no. (if yes, and you do not now possess an active license from the Virginia State Bar, explain t he details on a separate sheet of paper.) I (we) hereby certify that to the best of my (our) knowledge and bel ief this is an accurate statement of facts, and I (we) acknowledge a continuing duty to report any later discovered errors or i nconsistencies to the Clerk of Court. DATE PRINTED NAME OF REQUESTING PERSON SIGNATURE OF REQUESTING PERSON DATE PRINTED NAME OF REQUESTING PERSON SIGNATURE OF REQUESTING PERSON FORM CC-1650 (PAGE ONE OF ONE) 7/03 PDF American LegalNet, Inc. www.USCourtForms.com-