TRUST INFORMATION FORM Court File No. ...........................................................................
COMMONWEALTH OF VIRGINIA
VA. CODE § 64.2-1409
(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 ........................................ Page ......................
or Clerk's Instrument No.
.............................................................................. 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
........................................................................................................................................................................................
11. Name of additional person seeking appointment
................................................................................................................................................
12. Day telephone ............................................................................................. Night telephone .................................................................................
13. Residence address
............................................................................................................................................................................................................
14. Mailing address, if different
........................................................................................................................................................................................
15. The maximum value of assets to be held in the trust is estimated as follows:
(a) Personal Property $
.......................................
(b) Real Property $
.......................................
TOTAL VALUE OF TRUST $ ......................................
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 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 heet of paper.) s
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
