Fill and Sign the Virginia Guardian of Minor Information Form

GUARDIAN OF MINOR INFORMATION FORM Court File No.: ................................................................... COMMONWEALTH OF VIRGINIA VA. CODE §§ 64.2-1409, 64.2-1706 Circuit Court of ........................................................................\ ...............................................................................................................................\ ..................... 1. Minor’s full name ........................................................................\ ...............................................................................................................................\ ....... 2. Residence address (street, city, state) ........................................................................\ ................................................................................................ .......................................................................\ ....................................................... ........................................................................\ .............................................. 3. Date of birth: ........................................................................\ ................. Place of birth: ........................................................................\ ..................... 4. Qualification requested: [ ] guardian of person [ ] guardian of estate [ ] temporary guardian 5. Name of person making request: ........................................................................\ ......................................................................................................... 6. Mailing address: ........................................................................\ ...............................................................................................................................\ .......... 7. Basis for qualification: [ ] court order [ ] decedent’s will [ ] other (specify) ........................................................................\ ........... 8. Name of person seeking qualification: ........................................................................\ .............................................................................................. 8a. Relationship to minor, if any ........................................................................\ ........................................................................................................ 9. Day telephone ........................................................................\ .............. Night telephone ........................................................................\ .................. 10. Residence address ........................................................................\ ...............................................................................................................................\ ....... 11. Mailing address, if different ........................................................................\ .................................................................................................................. 12. Name of additional person seeking qualification: ........................................................................\ ........................................................................ 12a. Relationship to minor, if any ........................................................................\ ...................................................................................................... 13. Day telephone ........................................................................\ .............. Night telephone ........................................................................\ .................. 14. Residence address ........................................................................\ ...............................................................................................................................\ ....... 15. Mailing address, if different ........................................................................\ .................................................................................................................. 16. Name of assisting attorney, if any ........................................................................\ ............. Telephone ................................................................ 17. Attorney’s mailing address ........................................................................\ .................................................................................................................... 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 QUALIFICATION 18. Have you ever been convicted of a felony? [ ] yes [ ] no. 19. Have you ever filed for bankruptcy? [ ] yes [ ] no. 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.) 21. The value of the minor’s personal property (see instructions) is $ .................................................................... The value of the minor’s real estate (see instructions) is $ .................................................................... The total value of the minor’s entire estate (see instructions) is $ .................................................................... 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 QUALIFICAT ION SIGNATURE OF PERSON SEEKING QUALIFICATION ..................................................... .......................................................................\ .. ............. ______________________________________________ DATE PRINTED NAME OF PERSON SEEKING QUALIFICAT ION SIGNATURE OF PERSON SEEKING QUALIFICATION FORM CC-1653 MASTER 10/12