TRUST INFORMATION FORM COMMONWEALTH OF VIRGINIA VA. CODE § 64.2-1409 Court File No. ........................................................................... (For appointment/qualification of a trustee including court-ordered trusts and structured settlements.) Circuit Court of .......................................................................................................................................................................................................................... 1. Name of Estate or Settlor ............................................................................................................................................................................................. ........................................ 2. Is this a trust created by a will? [ ] yes [ ] no. If yes, will is recorded in Book or Clerk's Instrument No. .............................................................................. Page ...................... Date of Instrument .................................................................. 3. If court-ordered trust, date of order and case number 4. Name of person making request 5. Mailing address ....................................................................................................................................... ................................................................................................................................................................................ ................................................................................................................................................................................................................ 6. Basis for request: [ ] trustee named in will [ ] other (specify) ................................................................................................................ 7. Name of person seeking appointment 8. Day telephone ..................................................................................................................................................................... ............................................................................................. Night telephone ................................................................................. 9. Residence address ............................................................................................................................................................................................................ 10. Mailing address, if different 12. Day telephone ........................................................................................................................................................................................ ................................................................................................................................................ 11. Name of additional person seeking appointment ............................................................................................. Night telephone ................................................................................. 13. Residence address ............................................................................................................................................................................................................ 14. Mailing address, if different (a) Personal Property (b) Real Property TOTAL VALUE OF TRUST 16. Name of assisting attorney, if any ................................................................................ Telephone 17. Attorney's mailing address ........................................................................................................................................................................................ 15. The maximum value of assets to be held in the trust is estimated as follows: $ ....................................... $ ....................................... $ ...................................... ................................................................... .......................................................................................................................................................................................... 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 APPOINTMENT 18. Have you ever been convicted of a felony? [ ] yes [ ] no. (If yes, explain the details on a separate sheet of paper.) 19. Have you ever filed for bankruptcy? [ ] yes [ ] no. (If yes, explain the details on a separate sheet of paper.) 20. 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 from the Virginia State Bar, explain the details on a separate sheet of paper.) 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 APPOINTMENT __________________________________________________ SIGNATURE OF PERSON SEEKING APPOINTMENT ............................................ DATE ______________________________________________ PRINTED NAME OF PERSON SEEKING APPOINTMENT __________________________________________________ SIGNATURE OF PERSON SEEKING APPOINTMENT FORM CC-1654 MASTER 10/12 American LegalNet, Inc. www.FormsWorkFlow.com