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. Decedent's full name
[ ] Married [ ] Single [ ] Divorced [ ] Widowed
2. Decedent's Residence address at death (street, city, state)
Date and place of death
3. Date of birth
4. Proof of death: [ ] Death certificate [ ] Obituary [ ] Other (specify)
5. The decedent died: [ ] with a will [ ] without a will. Date of will (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
Night telephone
11. Day 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. Attorney's mailing address
20. The total value of the decedent's 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 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
21. Are you a person under a disability? [ ] yes [ ] no. (See Instructions 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 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 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
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