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2. Applicant Information
   Please list the following information for the applicant or the person making the request.
4. First Name (Applicant)*
5. Middle Initial (App)*
6. Last Name (Applicant)*
8. Address1 (Applicant)*
10. City (Applicant)*
11. State (Applicant)*
12. Zip (Applicant)*
14. Phone Number (Applicant)*
    Please list the easiest number you can be reached.
15. Relationship to Decedent (Applicant)*
17. Email Address (Applicant)
18. If there is a will are you the executor named in the will?*

    1. Yes
    2. No
19. Have you been convicted of felony?*

    1. Yes
    2. No
23. Decedent Information
    Please list the following information for the Decedent.
25. First Name (Decedent)*
26. Middle Initial (Dec)*
27. Last Name (Decedent)*
29. Home address at time of death (Decedent)*
31. City (Decedent)*
32. State (Decedent)*
33. Zip (Decedent)*
35. Marital Status*

    1. Married
    2. Single

    1. Divorced
    2. Widowed
36. Death Location*
    County/City of death
38. Date of Birth (Decedent)*
    Date of Birth (Decedent)
39. Date of Death (Decedent)*
    Date of Death (Decedent)
40. Age at Death (Decedent)
42. Did the Decedent leave a Will?*

    1. Yes
    2. No
43. What date was the Will signed?
    What date was the Will signed?
44. How many pages are in the Will?
46. Value of Personal Assets*
    List the total value of Personal assets that was in the decedent's name only at the time of his/her death.
47. Value of Real Estate*
    List the total value of all real estate that was solely in the decedent's name. Do not include property that was held jointly with the right of survivorship.
51. Heirs at Law
    Heirs at law are required to be listed. The heirs at law are next of kin according to 64.2-200 and do not necessarily inherit under the will. If you have any questions please refer to Qualification Instruction #2 or code 64.2-200.
53. First Name (Heir 1)*
54. Middle Initial(Heir1)*
55. Last Name (Heir 1)*
57. Address (Heir 1)*
58. City (Heir 1)*
59. State (Heir 1)*
61. Zip (Heir 1)*
62. Relationship to Decedent (Heir 1)*
63. Age (Heir 1)*
    At time of death
67. First Name (Heir 2)
68. Middle Initial(Heir 2)
69. Last Name (Heir 2)
71. Address (Heir 2)
72. City (Heir 2)
73. State (Heir 2)
75. Zip (Heir 2)
76. Relationship to Decedent (Heir 2)
77. Age (Heir 2)
81. First Name (Heir 3)
82. Middle Initial(Heir 3)
83. Last Name (Heir 3)
85. Address (Heir 3)
86. City (Heir 3)
87. State (Heir 3)
89. Zip (Heir 3)
90. Relationship to Decedent (Heir 3)
91. Age (Heir 3)
95. First Name (Heir 4)
96. Middle Initial(Heir 4)
97. Last Name (Heir 4)
99. Address (Heir 4)
100. City (Heir 4)
101. State (Heir 4)
103. Zip (Heir 4)
104. Relationship to Decedent (Heir 4)
105. Age (Heir 4)
107. If more than 4 heirs, please email their names and information to bchappell@vacourts.gov
111. Appointment Request
     Please submit the appointment time and date you would like and the Clerk will call or email as soon as possible.
113. Requested Appointment Day and Time
     Requested Appointment Day and Time Start Date

     Requested Appointment Day and Time Start Time

     —

     Requested Appointment Day and Time End Date

     Requested Appointment Day and Time End Time
     You can select a specific time or select a specific range of time you may be available for an appointment.
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115. 1. Receive an email copy of this form.
116. Email address

     This field is not part of the form submission.

117. Submit

* indicates a required field