Adult Information Form - Fairfax County
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3IN THE CIRCUIT COURT OF FAIRFAX
ADULT INFORMATION FORM
(For appointment of guardian, conservator, committee, or trustee for ex-service person)
PLEASE PRINT CLEARLY
Fiduciary Number ____________________
1. Ward’s full name: ____________________________________________________________________
2. Ward’s residence address (street, city, state): _______________________________________________
______________________________________________________________________________________
3. Ward’s date of birth: ____________________
Ward’s place of birth: ________________________
Married: _____
Never Married: _____
Divorced: _____
Widowed: _____
4. Ward’s social security number: Please use addendum to petition for appointment of Guardian or
Conservator – Under Seal (CC-1642)
5. Qualification requested:
Guardian
Conservator
Trustee for ex-service person
Committee
6. Name, address & telephone number for ALL PERSONS seeking appointment:
A.
Name: __________________________________________________________________
Address: ________________________________________________________________
Home phone: (_____)__________________ Work phone: (_____)__________________
Employer: _______________________________________________________________
Work address: ___________________________________________________________
B.
Name: __________________________________________________________________
Address: ________________________________________________________________
Home phone: (_____)__________________ Work phone: (_____)__________________
Employer: _______________________________________________________________
Work address: ___________________________________________________________
C.
Name: __________________________________________________________________
Address: ________________________________________________________________
Home phone: (_____)__________________ Work phone: (_____)__________________
Employer: _______________________________________________________________
Work address: ___________________________________________________________
L-10 Adult Information Form OCT 2012
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