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 QUALIFICATION SIGNATURE OF PERSON SEEKING QUALIFICATION
..................................................... ...................................................................................... ______________________________________________
DATE PRINTED NAME OF PERSON SEEKING QUALIFICATION SIGNATURE OF PERSON SEEKING QUALIFICATION
FORM CC-1653 MASTER 10/12
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