Guardian Of Minor Information Form {CC-1653}

GUARDIAN OF MINOR INFORMATION FORM COMMONWEALTH OF VIRGINIA VA. CODE §§ 64.2-1409, 64.2-1706 Court File No.: ................................................................... Circuit Court of ............................................................................................................................................................................................................................ 1. 2. 3. 4. 5. 6. 7. 8. 9. Minor's full name .............................................................................................................................................................................................................. ........................................................................................................................................................................ Residence address (street, city, state) .................................................................................................................................................................................................................................................... Date of birth: ......................................................................................... Place of birth: ............................................................................................. Qualification requested: [ ] guardian of person [ ] guardian of estate [ ] temporary guardian Name of person making request: Mailing address: ................................................................................................................................................................................. ................................................................................................................................................................................................................. ................................................................................... Basis for qualification: [ ] court order [ ] decedent's will [ ] other (specify) Name of person seeking qualification: ...................................................................................................................................................................... 8a. Relationship to minor, if any ................................................................................................................................................................................ 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 QUALIFICATION ______________________________________________ SIGNATURE OF PERSON SEEKING QUALIFICATION ..................................................... DATE ..........................