FOR REFERENCE ONLY 265 DC Forms List

User Manual: 265 DC

Open the PDF directly: View PDF PDF.
Page Count: 21

COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 1 of 21
FOR REFERENCE ONLY: This is a list of District Court Forms produced by the Office of the
Executive Secretary including their current revision dates. The list includes forms for public
use and forms used by court personnel only. Not all forms on this list are available and you
cannot link to the revisable Internet forms from this listing.
MISCELLANEOUS FORMS
Form #
Form Name
Form Type
Revision Date
DC-25
CIRCUIT COURT CASE TRANSMITTAL AND FEES REMITTANCE
SHEET
Master
07/15
DC-30
COMMONWEALTH OF VIRGINIA DRIVER’S LICENSE REINSTATEMENT
FORM
Master
12/05
DC-32
DELINQUENT PAYMENT RECORD
Master
10/14
DC-33
DELINQUENT COLLECTIONS REPORT
Master
05/09
DC-40
LIST OF ALLOWANCES
Printed
11/16 (front)
10/15 (reverse)
DC-40(a)
APPLICATION AND AUTHORIZATION FOR WAIVER OF FEE CAP
Master
01/08 (p. 1)
04/13 (p. 2)
DC-42
LIST OF ALLOWANCES FOR COMMONWEALTH WITNESS
Printed
10/89
DC-43
LIST OF ALLOWANCES FOR JURORS
Printed
12/88
DC-43(c)
LIST OF ALLOWANCES FOR JURORS – CONTINUATION SHEET
Printed
12/88
DC-44
LIST OF ALLOWANCES – INTERPRETER
Printed
10/17 (front)
07/08 (reverse)
DC-52
PUBLIC DEFENDER TIMESHEET
Printed
07/01
DC-60
INVOLUNTARY ADMISSION HEARING INVOICE
Printed
07/08 (front)
07/16 (reverse)
DC-90
ORDER DESIGNATING DISTRICT COURT JUDGE, RETIRED JUDGE OR
SUBSTITUTE JUDGE TO PRESIDE IN A DISTRICT COURT
Master
10/08
DC-91
ORDER OF DISQUALIFICATION/WAIVER OF DISQUALIFICATION
Master
12/01
COURT CASE FORMS – TRAFFIC DC-200S
Form #
Form Name
Revision Date
DC-201
NOTICE OF ADMINISTRATIVE SUSPENSION OF DRIVER’S
LICENSE/DRIVING PRIVILEGE
03/17 (front)
11/06 (reverse)
DC-202
MOTION FOR REVIEW OF ADMINISTRATIVE SUSPENSION OF
DRIVER’S LICENSE/DRIVING PRIVILEGE
10/08
DC-210
ACKNOWLEDGEMENT OF SUSPENSION OR REVOCATION OF
DRIVER’S LICENSE
10/17 (front)
10/17 (reverse)
DC-211
PETITION FOR PAYMENT AGREEMENT FOR FINES AND COSTS OR
MOTION TO MODIFY EXISTING AGREEMENT
Page 1, 07/17
Page 2, 07/17
DC-215
NOTICE OF DISHONORED CHECK OR CREDIT CARD CHARGE
11/06
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 2 of 21
COURT CASE FORMS – TRAFFIC DC-200S
Form #
Form Name
Revision Date
DC-216
COMPLIANCE WITH LAW CERTIFICATE
07/17
DC-217
VIRGINIA PREPAYABLE OFFENSES INFORMATION SHEET
07/17 (front)
10/12 (reverse)
DC-224
NOTICE TO PAY
10/12 (p. 1)
07/13 (p. 2)
DC-224
NOTICE TO PAY
(letter format only)
07/13
DC-225
NOTICE TO PAY AND NOTICE OF SUSPENSION FOR FAILURE TO PAY
11/16 (front)
11/16 (reverse)
DC-225
NOTICE TO PAY AND NOTICE OF SUSPENSION FOR FAILURE TO PAY
(letter format only)
10/17
DC-231
CERTIFICATE OF REFUSAL – BLOOD/BREATH TEST
WATERCRAFT OR MOTORBOATS
07/07 (p. 1)
07/07 (p. 2)
DC-232
CERTIFICATE OF REFUSAL – BLOOD/BREATH TEST
COMMERCIAL MOTOR VEHICLE
03/17
DC-233
DECLARATION AND ACKNOWLEDGEMENT OF REFUSAL –
BLOOD/BREATH TEST
07/17
DC-260
DRIVER’S LICENSE FORFEITURE/SUSPENSION AND RESTRICTED
DRIVING ORDER
(DC-261 is pages two and three of DC-260, DC-265, DC-279, DC-282,
DC-359, DC-576 & DC-577)
07/17 (p. 1, front)
07/10 (p. 1, reverse)
07/17 (p. 2)
07/17 (p. 3)
DC-261
RESTRICTED LICENSE ORDER
(DC-261 is pages two and three of DC-260, DC-265, DC-279, DC-282,
DC-359, DC-576 & DC-577)
07/17 (p.1)
07/17 (p. 2)
DC-262
ORDER TO ENTER INTO PROGRAM
10/12
DC-263
APPLICATION FOR RESTRICTED DRIVER’S LICENSE
10/13 (p. 1)
07/17 (p. 2)
DC-265
RESTRICTED DRIVER’S LICENSE ORDER AND ENTRY INTO ALCOHOL
SAFETY ACTION PROGRAM
(DC-261 is pages two and three of DC-260, DC-265, DC-279, DC-282,
DC-359, DC-576, & DC-577)
07/17 (p. 1, front)
07/10 (p. 1, reverse)
07/17 (p. 2)
07/17 (p. 3)
DC-266
RESTRICTED LICENSE CONDITIONS – IGNITION INTERLOCK ORDER
10/17 (front)
07/12 (reverse)
DC-267
OUT OF SERVICE ORDER – DRIVER
07/17
DC-270
PETITION FOR AUTHORIZATION FOR RESTRICTED DRIVER’S
LICENSE – FAILURE TO PAY FINES AND COSTS
07/17 (front)
07/17 (reverse)
DC-271
AUTHORIZATION FOR RESTRICTED DRIVER’S LICENSE – FAILURE TO
PAY FINES AND COSTS
07/17 (front)
07/08 (reverse)
DC-273
PETITION FOR AUTHORIZATION FOR RESTRICTED DRIVER’S
LICENSE – CONVICTION FOR UNAUTHORIZED DRIVING
10/09 (p. 1)
07/17 (p. 2)
DC-274
AUTHORIZATION FOR RESTRICTED DRIVER’S LICENSE –
CONVICTION FOR UNAUTHORIZED DRIVING
07/17 (front)
11/10 (reverse)
DC-276
PETITION AND ORDER FOR APPROVAL OF JAIL FEES PAYMENT
AGREEMENT
07/12 (p. 1)
07/12 (p. 2)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 3 of 21
COURT CASE FORMS – TRAFFIC DC-200S
Form #
Form Name
Revision Date
DC-277
PETITION AND ORDER AUTHORIZING SUSPENSION OR NONRENEWAL
OF DRIVER'S LICENSE – FAILURE TO PAY JAIL FEE
07/12 (p. 1)
07/12 (p. 2)
DC-278
PETITION FOR RESTRICTED DRIVER'S LICENSE – FAILURE TO PAY
JAIL FEE
07/17
DC-279
RESTRICTED DRIVER'S LICENSE ORDER – FAILURE TO PAY JAIL FEE
(DC-261 is pages two and three of DC-260, DC-265, DC-279, DC-282,
DC-359, DC-576, & DC-577)
07/17 (p. 1, front)
07/12 (p.1, reverse)
07/17 (p. 2)
07/17 (p. 3)
DC-280
PETITION AND ORDER TO SUSPEND DRIVER’S LICENSE – FAILURE
TO PAY CHILD SUPPORT
07/15
DC-281
PETITION FOR RESTRICTED DRIVER’S LICENSE – FAILURE TO PAY
CHILD SUPPORT
07/17
DC-282
RESTRICTED DRIVER’S LICENSE ORDER – FAILURE TO PAY CHILD
SUPPORT
(DC-261 is pages two and three of DC-260, DC-265, DC-279, DC-282,
DC-359, DC-567 & DC-577)
07/17 (p. 1, front)
10/08 (p.1, reverse)
07/17 (p. 2)
07/17 (p. 3)
DC-284
MOTION TO DISMISS TOLL ROAD SUMMONS
07/11
DC-285
SUMMONS FOR TOLL ROAD OR DESIGNATED ACCESS HIGHWAY
VIOLATION
11/16 (p. 1)
11/16 (p. 2)
DC-286
DISPOSITION ORDER – UNIFORM SUMMONS
10/17
DC-287
SUMMONS FOR HIGH-OCCUPANCY TOLL (HOT) LANE VIOLATION
11/16 (p. 1)
11/16 (p. 2)
COURT CASE FORMS – CRIMINAL DC-300S
Form #
Form Name
Form Type
Revision Date
DC-301
REQUEST FOR CONFIDENTIALITY BY CRIME VICTIM
Master
07/14
DC-302
REQUEST FOR COPY OF CERTIFICATE OF ANALYSIS
Master
10/08
DC-303
MOTION FOR TRANSMISSION OF BLOOD SAMPLE
Master
07/05
DC-304
NOTICE, MOTION AND ORDER FOR CHEMICAL ANALYSIS OF
ALLEGED PLANT MATERIAL
Printed
10/08
DC-305
OBJECTION TO ADMISSION OF CERTIFICATE OF ANALYSIS/VIDEO
TESTIMONY
Master
07/10
DC-306
OBJECTION TO ADMISSION OF AFFIDAVIT
Master
07/10
DC-307
CERTIFICATE FOR THE USE OF CANNABIDIOL OIL OR THC-A OIL
Master
03/17
DC-308
AFFIDAVIT FOR SEARCH WARRANT FOR REAL-TIME LOCATION
DATA
Master
07/17 (p. 1)
07/15 (p. 2)
DC-309
SEARCH WARRANT FOR REAL-TIME LOCATION DATA
Master
07/15 (p. 1)
07/15 (p. 2)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 4 of 21
COURT CASE FORMS – CRIMINAL DC-300S
Form #
Form Name
Form Type
Revision Date
DC-310
CRIMINAL COMPLAINT (BAD CHECK)
Printed
07/11
DC-311
CRIMINAL COMPLAINT
Printed
07/11
DC-312
WARRANT OF ARREST – FELONY
Master
10/13 (p. 1)
10/17 (p. 2)
DC-314
WARRANT OF ARREST – MISDEMEANOR (STATE)
Master
07/11 (p. 1)
10/17 (p. 2)
DC-315
WARRANT OF ARREST – MISDEMEANOR (LOCAL)
Master
07/11 (p. 1)
10/17 (p. 2)
DC-317
ORDER FOR RESTITUTION
Master,
Printed
Page 1, 10/17
Page 2, 07/17
DC-317-S1
SUPPLEMENTAL SHEET TO ORDER FOR RESTITUTION FOR VICTIM
INFORMATION
Master,
Printed
07/17
DC-317-S2
SUPPLEMENTAL SHEET TO ORDER FOR RESTITUTION FOR CO-
DEFENDANT INFORMATION
Master,
Printed
10/17
DC-319
SUMMONS
Master
07/11 (p. 1)
10/17 (p. 2)
DC-320
WARRANT OF ARREST – ILLEGAL ALIEN PURSUANT TO 19.2-81.6
Master
07/04
DC-321
SUMMONS OF CORPORATION OR LEGAL ENTITY – MISDEMEANOR
OR FELONY
Master
10/09
DC-322
ORDER – TRANSFER OF JURISDICTION
Master
07/92
DC-323
RECALL OF PROCESS
Printed
10/17
DC-324
NOTICE – APPEARANCE, WAIVER AND PLEA
Master
05/07
DC-325
REQUEST FOR WITNESS SUBPOENA
Printed
10/08
DC-326
SUBPOENA FOR WITNESS
Printed
10/08 (front)
07/14 (reverse)
DC-326x
SUBPOENA FOR WITNESS (continuous paper)
Printed
10/08 (front)
07/14 (reverse)
DC-327
CHECKLIST FOR BAIL DETERMINATIONS
Printed
07/13 (front)
07/15 (reverse)
DC-328
MOTION AND ORDER TO TRY DEFENDANT FOR A MISDEMEANOR
WITHOUT APPOINTMENT OF COUNSEL
Master
07/14
DC-329
RECOGNIZANCE (WITNESS)
Printed
07/11
DC-330
RECOGNIZANCE
Master
10/11 (p. 1)
10/13 (p. 2)
07/12 (p. 3)
DC-331
SURETY’S CAPIAS AND BAILPIECE RELEASE
Printed
07/14
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 5 of 21
COURT CASE FORMS – CRIMINAL DC-300S
Form #
Form Name
Form Type
Revision Date
DC-332
AFFIDAVIT FOR SURETY
Printed
11/07
DC-333
FINANCIAL STATEMENT – ELIGIBILITY DETERMINATION FOR
INDIGENT DEFENSE SERVICES
Printed
10/11
DC-334
REQUEST FOR APPOINTMENT OF A LAWYER
Printed
11/06
DC-335
WAIVER OF RIGHT TO REPRESENTATION BY A LAWYER
Printed
07/14
DC-336
SUBPOENA DUCES TECUM
Printed
06/06 (front)
07/04 (reverse)
DC-338
AFFIDAVIT FOR SEARCH WARRANT
Master
07/17 (p. 1)
07/17 (p. 2)
DC-339
SEARCH WARRANT
Master
07/17 (p. 1)
01/09 (p. 2)
DC-340
AFFIDAVIT FOR SEARCH WARRANT FOR TRACKING DEVICE
Master
07/12 (p. 1)
07/14 (p. 2)
DC-341
SEARCH WARRANT FOR TRACKING DEVICE
Master
04/12 (p. 1)
04/12 (p. 2)
DC-342
ORDER FOR PSYCHOLOGICAL EVALUATION
Master
07/14 (p. 1)
07/10 (p. 2)
DC-343
TRACKING DOCUMENT FOR SENDING OR RECEIVING EVALUATION
OR TREATMENT ORDER UPON ENTRY
Master
07/16
DC-344
MOTION TO WAIVE COURT APPEARANCE
Master
10/13
DC-345
ORDER FOR TREATMENT OF INCOMPETENT DEFENDANT
Master
10/17
DC-346
NOTICE OF HEARING DATE
Printed
12/84
DC-346
NOTICE OF HEARING DATE
(letter format only)
Printed
11/10
DC-347
CONTINUANCE CARD NOTICE/APPEARANCE REMINDER NOTICE
Printed
11/92
DC-348
NOTICE TO INDIVIDUAL – SUBPOENA DUCES TECUM FOR MEDICAL
RECORDS
Master
07/04
DC-349
NOTICE OF OPPORTUNITY TO HIRE COUNSEL AND/OR INELIGIBILITY
FOR APPOINTED COUNSEL; ORDER
Printed
07/14
DC-350
NOTICE TO HEALTH CARE PROVIDERS – SUBPOENA DUCES TECUM
FOR MEDICAL RECORDS
Master
07/04
DC-351
CHARGE ADDENDUM
Master
10/13
DC-352
COMMITMENT ORDER
Master
05/09 (p. 1)
07/13 (p. 2)
DC-353
RELEASE ORDER
Master
05/09
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 6 of 21
COURT CASE FORMS – CRIMINAL DC-300S
Form #
Form Name
Form Type
Revision Date
DC-354
CUSTODIAL TRANSPORTATION ORDER
Master
05/09
DC-355
ORDER FOR CONTINUED CUSTODY
Printed
07/11
DC-356
DISPOSITION NOTICE
Printed
10/17
DC-356-A
DISPOSITION NOTICE ADDENDUM
Master
03/08
DC-357
ORDER REGARDING SUBSTANCE ABUSE SCREENING – ADULT
MISDEMEANOR
Master
10/08
DC-358
ENTRY INTO ALCOHOL REHABILITATION PROGRAM (BOAT)
Master
10/08
DC-359
FORFEITURE OF DRIVER’S LICENSE AND RESTRICTED DRIVER’S
LICENSE ORDER – DRUG VIOLATION
DC-261 is pages two and three of DC-260, DC-265, DC-279, DC-282,
DC-359, DC-576 & DC-577)
Printed
07/17 (p. 1, front)
07/10 (p. 1, reverse)
07/17 (p. 2)
07/17 (p. 3)
DC-360
SHOW CAUSE SUMMONS (CRIMINAL)
Master
10/14 (p. 1)
11/16 (p. 2)
DC-360x
SHOW CAUSE SUMMONS (CRIMINAL) continuous paper
Printed
10/14 (front)
11/16 (reverse)
DC-361
CAPIAS – ATTACHMENT OF THE BODY
Master
10/14 (p. 1)
11/16 (p. 2)
DC-361x
CAPIAS – ATTACHMENT OF THE BODY continuous paper
Printed
10/14 (front)
11/16 (reverse)
DC-362
MOTION AND AFFIDAVIT REQUESTING COSTS FOR COMPUTER
FORENSIC ANALYSIS
Master
07/11
DC-363
PETITION OR MOTION FOR EXPUNGEMENT
Master
05/15
DC-364
RECOGNIZANCE AND BOND TO KEEP THE PEACE
Master
10/15 (p. 1)
07/12 (p. 2)
DC-365
EXPUNGEMENT ORDER
Master
07/11
DC-366
CERTIFICATE OF INCARCERATION PERIOD
Master
07/16
DC-366A
REQUEST FOR WAIVER OF INTEREST OF FINES AND COSTS
Master
07/16
DC-367
APPLICATION, REQUEST, ORDER AND CERTIFICATE OF
DESTRUCTION OF CONTROLLED/CONFISCATED ITEMS
Master
10/17
DC-368
MOTION TO REOPEN (CRIMINAL)/MOTION TO REHEAR (CIVIL)/
MOTION FOR NEW TRIAL (CIVIL)
(the reverse side of DC-368 is the reverse for DC-433 & DC-434)
Printed
10/11 (front)
06/06 (reverse)
DC-370
NOTICE OF APPEAL – CRIMINAL
Printed
11/16
DC-371
MOTION AND NOTICE OF HEARING
Master
10/12 (p. 1)
05/09 (p. 2)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 7 of 21
COURT CASE FORMS – CRIMINAL DC-300S
Form #
Form Name
Form Type
Revision Date
DC-372
AUTHENTICATION OF RECORD (in-state usage)
Master
10/07
DC-373
NOTICE OF ISSUANCE OF EMERGENCY PROTECTIVE ORDER
Printed
11/16 (p. 1, front)
11/16 (p. 1&4, reverse)
11/16 (p. 2&3, reverse)
DC-374
WARRANT OF ARREST FOR EXTRADITION
Master
07/05 (p. 1)
07/05 (p. 2)
DC-375
WAIVER OF EXTRADITION PROCEEDINGS
Master
10/07
DC-376
AFFIDAVIT FOR FIRE INVESTIGATION WARRANT
Master
07/17
DC-377
FIRE INVESTIGATION WARRANT
Master
07/14
DC-378
AFFIDAVIT FOR DAM INSPECTION WARRANT
Master
07/17
DC-379
DAM INSPECTION WARRANT
Master
07/14
DC-380
AFFIDAVIT FOR FIRE INSPECTION WARRANT
Master
07/17 (p. 1)
07/14 (p. 2)
DC-381
FIRE INSPECTION WARRANT
Master
07/14 (p. 1)
05/88 (p. 2)
DC-382
EMERGENCY PROTECTIVE ORDER
Printed
07/16 (p. 1, front)
07/16 (p.1 & 4, reverse)
07/16 (p.2 & 3, reverse)
DC-383
PETITION FOR PROTECTIVE ORDER
Master
10/14 (p. 1)
04/13 (p. 2)
DC-384
PRELIMINARY PROTECTIVE ORDER
Master
07/14 (p. 1)
04/13 (p. 2)
DC-385
PROTECTIVE ORDER
Master
10/14 (p. 1)
10/12 (p. 2)
DC-386
AFFIDAVIT FOR PESTICIDE CONTROL ADMINISTRATIVE SEARCH
WARRANT
Master
07/17 (p. 1)
07/14 (p. 2)
DC-387
PESTICIDE CONTROL ADMINISTRATIVE SEARCH WARRANT
Master
07/14 (p. 1)
05/00 (p. 2)
DC-388
AFFIDAVIT FOR RELEASE OF HAZARDOUS MATERIAL OR WASTE OR
REGULATED SUBSTANCE INVESTIGATION WARRANT
Master
07/17 (p. 1)
07/14 (p. 2)
DC-389
RELEASE OF HAZARDOUS MATERIAL OR WASTE OR REGULATED
SUBSTANCE INVESTIGATION WARRANT
Master
07/14
DC-390
AFFIDAVIT FOR BUILDING INSPECTION WARRANT
Master
07/17 (p. 1)
07/14 (p. 2)
DC-391
BUILDING INSPECTION WARRANT
Master
07/14 (p. 1)
07/01 (p. 2)
DC-392
SEALED DOCUMENTS
Printed
05/03
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 8 of 21
COURT CASE FORMS – CRIMINAL DC-300S
Form #
Form Name
Form Type
Revision Date
DC-393
PETITION FOR HIV OR HEPATITIS B OR C VIRUSES TESTING
PURSUANT TO 18.2-62
Master
01/09
DC-394
DENIAL/DISMISSAL ORDER IN PROTECTIVE ORDER CASES
Master
10/11 (p.1)
10/11 (p.2)
DC-395
AFFIDAVIT FOR SUMMONS FOR DANGEROUS DOG OR VICIOUS DOG
Master
07/13
DC-396
SUMMONS – DANGEROUS DOG OR VICIOUS DOG
Master
10/13 (p. 1)
07/17 (p. 2)
DC-397
AFFIDAVIT FOR WARRANT FOR DEPREDATION BY DOG
Master
07/16
DC-398
WARRANT – DEPREDATION BY DOG
Master
07/16 (p. 1)
07/16 (p. 2)
DC-399
SEARCH WARRANT – CRUELTY TO ANIMALS
Master
07/14
COURT CASE FORMS – CIVIL DC-400S
Form #
Form Name
Form Type
Revision Date
DC-400
MEDIATION ORIENTATION ORDER OF REFERRAL
Master
10/07 (p. 1)
10/08 (p. 2)
DC-401
ORDER FOR APPOINTMENT OF GUARDIAN AD LITEM
Master
07/97
DC-402
WARRANT IN DEBT – SMALL CLAIMS DIVISION
Printed
10/07 (front)
07/01 (reverse)
DC-404
WARRANT IN DETINUE – SMALL CLAIMS DIVISION
Master
05/08 (p. 1)
05/08 (p. 2)
DC-405
PETITION TO TEST FOR BLOOD – BORNE PATHOGENS
Master
07/08 (p. 1)
10/97 (p. 2)
DC-406
PETITION TO REQUIRE BLOOD TEST
Master
07/15 (p. 1)
10/12 (p. 2)
DC-407
REQUEST FOR HEARING – EXEMPTION CLAIM
Printed
07/15 (front)
07/12 (reverse)
DC-410
AFFIDAVIT FOR SERVICE OF PROCESS ON THE SECRETARY OF THE
COMMONWEALTH
Printed
07/13 (front)
11/07 (reverse)
DC-411
SERVICE OTHER THAN BY VIRGINIA SHERIFF
Master
10/08
DC-412
WARRANT IN DEBT
Printed
07/04 (front)
07/04 (reverse)
DC-412x
WARRANT IN DEBT (continuous paper)
Printed
07/04 (front)
07/04 (reverse)
DC-413
CERTIFICATE OF MAILING POSTED SERVICE
Master
06/99
DC-414
WARRANT IN DETINUE
Printed
07/04 (front)
07/04 (reverse)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 9 of 21
COURT CASE FORMS – CIVIL DC-400S
Form #
Form Name
Form Type
Revision Date
DC-415
DETINUE SEIZURE PETITION
Master
05/04 (p. 1)
05/04 (p. 2)
DC-416
DETINUE SEIZURE ORDER
Master
12/00 (p. 1)
06/89 (p. 2)
DC-417
ORDER FOR STAY – SERVICEMEMBERS CIVIL RELIEF ACT
Master
07/16
DC-418
AFFIDAVIT – DEFAULT JUDGMENT – SERVICEMEMBERS CIVIL
RELIEF ACT
Printed
11/16
DC-419
MOTION AND ORDER FOR VOLUNTARY NONSUIT
Master
07/07 (p. 1)
07/07 (p. 2)
DC-420
MOTION FOR SHOW CAUSE SUMMONS OR CAPIAS (General District)
Printed
10/08
DC-421
SUMMONS FOR UNLAWFUL DETAINER
Printed
10/17 (front)
10/17 (reverse)
DC-422
NOTICE OF HEARING TO ESTABLISH FINAL RENT AND DAMAGES
Master
07/14
DC-423
DISTRESS PETITION
Master
07/09 (p. 1)
07/93 (p. 2)
DC-424
DISTRESS WARRANT
Master
10/07 (p. 1)
06/89 (p. 2)
DC-428
WARRANT IN DEBT – INTERPLEADER
Master
07/10 (p. 1)
10/07 (p. 2)
DC-429
TENANT’S ASSERTION AND COMPLAINT
Master
07/16 (p. 1)
10/15 (p. 2)
DC-430
SUMMONS FOR HEARING
Master
10/15 (p. 1)
06/95 (p. 2)
DC-431
TENANT’S PETITION FOR RELIEF FROM UNLAWFUL EXCLUSION
Master
07/13 (p. 1)
07/13 (p. 2)
DC-432
AFFIDAVIT FOR SUMMONS IN INTERPLEADER
Master
11/10
DC-433
SUMMONS IN INTERPLEADER AND ORDER FOR POSTPONEMENT OF
SALE
Master
06/89 (p. 1)
06/06 (p. 2)
DC-434
MOTION TO SET ASIDE DEFAULT JUDGMENT
(the reverse side of DC-368 is the reverse for DC-433 & DC-434)
Master
10/11 (front)
06/06 (reverse)
DC-435
AFFIDAVIT AND PETITION FOR ORDER OF PUBLICATION
Master
11/10
DC-436
ORDER OF PUBLICATION
Master
07/15
DC-437
NOTICE OF CHANGE OF ADDRESS
Master
10/08
DC-440
SUMMONS TO ANSWER INTERROGATORIES AND WRIT OF FIERI
FACIAS
Printed
10/17 (front)
07/03 (reverse)
DC-441
BILL OF PARTICULARS
Master
05/09
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 10 of 21
COURT CASE FORMS – CIVIL DC-400S
Form #
Form Name
Form Type
Revision Date
DC-442
GROUNDS OF DEFENSE
Master
05/09
DC-443
ITEMIZED LIST OF DAMAGES
Master
05/09
DC-445
ATTACHMENT PETITION
Master
07/15 (p. 1)
07/93 (p. 2)
DC-446
ATTACHMENT SUMMONS
Master
07/11 (p. 1)
06/89 (p. 2)
DC-447
PLAINTIFF’S BOND FOR LEVY OR SEIZURE
Master
07/93
DC-448
DEFENDANT’S BOND FOR LEVY OR SEIZURE
Master
07/93
DC-449
AFFIDAVIT CONCERNING DEPENDENT CHILDREN AND HOUSEHOLD
INCOME
Master
07/09
DC-450
SUGGESTION FOR SUMMONS IN GARNISHMENT
Printed
07/12 (front)
04/84 (reverse)
DC-451
GARNISHMENT SUMMONS
Printed
01/07 (front)
01/07 (reverse)
DC-451a
GARNISHMENT STATUTE
Master
10/11
DC-453
GARNISHMENT DISPOSITION
Master
10/13
DC-454
REQUEST FOR HEARING – GARNISHMENT/LIEN EXEMPTION CLAIM
Printed
07/10 (front)
07/12 (reverse)
DC-455
GARNISHEE INFORMATION SHEET
Printed
10/11 (front)
10/15 (reverse)
DC-456
GARNISHEE’S ANSWER
Printed
10/17
DC-458
NOTICE OF SATISFACTION
Printed
07/17
DC-459
MOTION FOR JUDGMENT TO BE MARKED SATISFIED
Master
07/15 (p. 1)
10/07 (p. 2)
DC-460
CIVIL APPEAL BOND
Master
10/11
DC-462
PLAINTIFF’S BOND – LIEN OF MECHANIC FOR REPAIRS
Master
07/16
DC-463
SUMMONS – LIEN OF MECHANIC FOR REPAIRS
Master
07/16 (p. 1)
06/89 (p. 2)
DC-465
ABSTRACT OF JUDGMENT
Master
07/07
DC-467
WRIT OF FIERI FACIAS
Master
10/07 (p. 1)
03/82 (p. 2)
DC-468
WRITS OF POSSESSION AND FIERI FACIAS IN DETINUE
Master
05/09 (p. 1)
05/09 (p. 2)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 11 of 21
COURT CASE FORMS – CIVIL DC-400S
Form #
Form Name
Form Type
Revision Date
DC-469
REQUEST FOR WRIT OF POSSESSION IN UNLAWFUL DETAINER
PROCEEDINGS
Printed
11/16
DC-470
FORTHCOMING BOND
Master
01/81
DC-472
PETITION FOR REINSTATEMENT OF DRIVING PRIVILEGES
Master
07/03 (p. 1)
07/03 (p. 2)
DC-473
ORDER FOR REINSTATEMENT OF DRIVING PRIVILEGES
Master
07/03
DC-475
NOTICE OF APPEAL – CIVIL
Printed
07/11
DC-476
NOTICE AND MOTION TO CURE DEFICIENCIES – CIVIL APPEAL
Master
07/11 (p. 1)
11/07 (p. 2)
DC-477
PETITION FOR JUDICIAL CERTIFICATION OF ELIGIBILITY FOR
ADMISSION
Master
07/12
DC-478
CERTIFICATION OF ELIGIBILITY FOR ADMISSION
Master
07/12
DC-479
PETITION AND ORDER FOR SALE OF PROPERTY
Master
07/16 (p. 1)
10/12 (p. 2)
DC-480
CASE DISPOSITION
Master
10/11
DC-481x
SHOW CAUSE SUMMONS (CIVIL) continuous paper
Printed
10/13 (front)
10/13 (reverse)
DC-482
SHOW CAUSE SUMMONS (BOND FORFEITURE CIVIL)
Master
10/13 (p. 1)
07/06 (p. 2)
DC-483x
CAPIAS: ATTACHMENT OF THE BODY (CIVIL) continuous paper
Printed
10/14 (front)
10/13 (reverse)
DC-485
PETITION FOR RESTORATION OF DRIVING PRIVILEGE – HABITUAL
OFFENDER
Master
07/10 (p. 1)
10/07 (p. 2)
07/98 (p. 3)
DC-486
ORDER FOR EVALUATION – HABITUAL OFFENDER
Master
01/96
DC-487
ORDER RESTORING DRIVING PRIVILEGE – HABITUAL OFFENDER
Master
07/10 (p. 1)
10/08 (p. 2)
07/17 (p. 3)
DC-488
MEDICAL EMERGENCY CUSTODY ORDER
Master
11/10
DC-489
MEDICAL EMERGENCY TEMPORARY DETENTION PETITION
Master
07/15
DC-489A
MEDICAL TREATMENT AND DETENTION PETITION
Master
07/12
DC-490
MEDICAL EMERGENCY TEMPORARY DETENTION ORDER
Master
07/15 (p. 1)
12/03 (p. 2)
DC-490A
MEDICAL TREATMENT AND DETENTION ORDER
Master
07/12
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 12 of 21
COURT CASE FORMS – CIVIL DC-400S
Form #
Form Name
Form Type
Revision Date
DC-491
MEDICAL EMERGENCY CUSTODY PETITION
Master
11/10
DC-492
EMERGENCY CUSTODY ORDER
Master
07/16 (p. 1)
07/16 (p. 2)
DC-493
EXPLANATION OF INVOLUNTARY COMMITMENT PROCESS –
DESCRIPTION OF RIGHTS
Printed
11/10
DC-494A
TEMPORARY DETENTION ORDER – JUDGE
Printed
07/14 (front)
07/16 (reverse)
DC-495
PETITION FOR INJUNCTION OR MANDAMUS – FREEDOM OF
INFORMATION ACT AND AFFIDAVIT FOR GOOD CAUSE OR
PROTECTION OF SOCIAL SECURITY NUMBERS ACT
Master
07/09
DC-496
ORDER FOR PETITION FOR INJUNCTION OR WRIT OF MANDAMUS
Master
07/09
DC-497
SUBPOENA FOR WITNESS – ATTORNEY ISSUED
Master
04/13 (p. 1)
04/13 (p. 2)
DC-498
SUBPOENA DUCES TECUM – ATTORNEY ISSUED
Master
07/01 (p. 1)
07/04 (p. 2)
DC-499
MOTION AND ORDER FOR RELEASE OF VEHICLE
Master
07/10 (p. 1)
11/10 (p. 2)
COURT CASE FORMS – MENTAL HEALTH (ADULT) DC-4000S
Form #
Form Name
Form Type
Revision Date
DC-4000
ORDER FOR ALTERNATIVE TRANSPORTATION PROVIDER
Master
07/15
DC-4001
PETITION FOR INVOLUNTARY ADMISSION FOR TREATMENT
Master
07/15 (p. 1)
07/13 (p. 2)
DC-4002
ORDER FOR TREATMENT
Master
07/12 (p. 1)
07/12 (p. 2)
07/12 (p. 3)
07/16 (p. 4)
DC-4003
ORDER FOR TREATMENT OF INMATE
Master
07/17 (p. 1)
07/12 (p. 2)
DC-4005
PETITION FOR REVIEW OF MANDATORY OUTPATIENT TREATMENT
Master
07/10 (p. 1)
07/10 (p. 2)
DC-4007
ORDER – REVIEW OF MANDATORY OUTPATIENT TREATMENT
Master
07/12 (p. 1)
07/16 (p. 2)
DC-4008
ORDER OF APPOINTMENT OF EXAMINER – EXAMINATION FOR
INVOLUNTARY TREATMENT
Master
07/10
DC-4010
PETITION FOR RESCISSION OF MANDATORY OUTPATIENT
TREATMENT
Master
07/10
DC-4012
ORDER – RESCISSION OF MANDATORY OUTPATIENT TREATMENT
Master
07/12 (p. 1)
07/12 (p. 2)
07/16 (p. 3)
DC-4015
PETITION TO CONTINUE MANDATORY OUTPATIENT TREATMENT
Master
07/10
DC-4017
ORDER – CONTINUE MANDATORY OUTPATIENT TREATMENT
Master
07/12 (p. 1)
07/12 (p. 2)
07/16 (p. 3)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 13 of 21
COURT CASE FORMS – MENTAL HEALTH (ADULT) DC-4000S
Form #
Form Name
Form Type
Revision Date
DC-4020
TRACKING DOCUMENT FOR SENDING OR RECEIVING MANDATORY
OUTPATIENT TREATMENT ORDER UPON ENTRY
Master
07/16
DC-4022
TRACKING DOCUMENT FOR SENDING OR RECEIVING MANDATORY
OUTPATIENT TREATMENT ORDER UPON TRANSFER
Master
07/16
DC-4024
ORDER – TRANSFER OF JURISDICTION PURSUANT TO VIRGINIA
CODE § 37.2-817 J
Master
10/14
DC-4026
CAPIAS: TRANSPORT AND MANDATORY EXAMINATION ORDER
Master
05/15
DC-4029
APPLICATION FOR COPY OF RECORDING OF COMMITMENT
HEARING
Master
07/08
DC-4032
WAIVER OF CONFIDENTIALITY OF COURT RECORDS –
COMMITMENT FOR MENTAL HEALTH TREATMENT
Master
07/08
DC-4035
PETITION AND ORDER FOR ACCESS TO DISPOSITIONAL ORDER
Master
07/08
DC-4035(A)
ORDER FOR ACCESS TO DISPOSITIONAL ORDER
Master
07/08
DC-4040
PETITION TO RESTORE RIGHT TO PURCHASE, POSSESS OR
TRANSPORT A FIREARM
Master
10/13
DC-4042
ORDER – RESTORATION OF RIGHT TO PURCHASE, POSSESS OR
TRANSPORT A FIREARM
Master
07/11
DC-4044
NOTICE OF ALTERNATIVE FACILITY OF TEMPORARY DETENTION
Master
07/14
DC-4046
ORDER FOR TRANSPORTATION TO ALTERNATIVE FACILITY OF
TEMPORARY DETENTION
Master
07/14
DC-4050
EXPLANATION OF EMERGENCY CUSTODY PROCEDURE
Printed
07/14
COURT CASE FORMS – JUVENILE DC-500S
Form #
Form Name
Form Type
Revision Date
DC-501
ORDER TO CLOSE HEARING
Master
07/96
DC-502A
PETITION FOR JUDICIAL AUTHORIZATION OF ABORTION
Master
07/12
DC-502B
ADVISEMENT OF YOUR RIGHT TO COUNSEL
Master
07/12
DC-502C
ACKNOWLEDGEMENT OF RIGHT TO COUNSEL AND APPOINTMENT OF
COUNSEL
Master
07/12
DC-502D
ORDER IN PROCEEDING FOR JUDICIAL AUTHORIZATION OF
ABORTION
Master
07/12
DC-502E
NOTICE OF APPEAL – JUDICIAL AUTHORIZATION OF ABORTION
Master
07/12
DC-503
PETITION FOR COURT APPROVAL OF STANDBY GUARDIAN
Master
10/15 (p. 1)
07/98 (p. 2)
DC-504
NOTICE OF PETITION FOR COURT APPROVAL OF STANDBY
GUARDIAN
Master
10/15
DC-505
ORDER APPROVING STANDBY GUARDIAN
Master
10/15 (p. 1)
07/98 (p. 2)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 14 of 21
COURT CASE FORMS – JUVENILE DC-500S
Form #
Form Name
Form Type
Revision Date
DC-506
NOTICE OF REVOCATION/STATEMENT OF REFUSAL – STANDBY
GUARDIAN
Master
10/15
DC-507
PETITION FOR ORDER OF EMANCIPATION
Master
07/16
DC-508
ACKNOWLEDGEMENT OF NOTICE OF NEXT HEARING DATE
Master
11/16
DC-509
AFFIDAVIT/CERTIFICATION OF PARENTAL IDENTITY OR LOCATION
Master
10/15
DC-510
SUMMONS
Master
07/09 (p. 1)
07/17 (p. 2)
DC-510x
SUMMONS (continuous paper)
Printed
07/09 (front)
07/17 (reverse)
DC-511
PETITION
Master
11/16 (p. 1)
12/01 (p. 2)
DC-512
NOTICE OF HEARING
Printed
10/08
DC-513
ADVISEMENT AND REQUEST FOR APPOINTMENT OF COUNSEL
Printed
05/07
DC-514
ORDER FOR APPOINTMENT OF GUARDIAN AD LITEM
Printed
10/14 (front)
09/03 (reverse)
DC-515
WAIVER OF RIGHT TO BE REPRESENTED BY A LAWYER (JUVENILE)
Printed
05/07
DC-517
WAIVER OF JURISDICTION
Master
10/07
DC-518
TRANSFER/RETENTION ORDER
Master
10/15 (p. 1)
07/12 (p. 2)
DC-519
NOTICE OF TRANSFER HEARING
Master
05/96 (p. 1)
01/81 (p. 2)
DC-520
CERTIFICATION OF JUVENILE FELONY CHARGE
Master
07/96
DC-522
ORDER FOR EVALUATION TO DETERMINE COMPETENCY TO STAND
TRIAL – JUVENILE
Master
07/09 (p. 1)
07/99 (p. 2)
DC-523
ORDER FOR PROVISION OF RESTORATION SERVICES TO
INCOMPETENT JUVENILE
Master
07/09
DC-524
NOTICE OF RIGHT TO CONSIDERATION OF DIVERSION
Printed
10/11
DC-526
EMERGENCY REMOVAL ORDER
Master
07/17 (p. 1)
07/17 (p. 2)
10/15 (p. 3)
DC-527
PRELIMINARY CHILD PROTECTIVE ORDER – ABUSE AND NEGLECT
Master
11/16 (p. 1)
10/15 (p. 2)
10/15 (p. 3)
10/15 (p. 4)
DC-528
PRELIMINARY REMOVAL ORDER
Master
07/17 (p. 1)
07/17 (p. 2)
10/15 (p. 3)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 15 of 21
COURT CASE FORMS – JUVENILE DC-500S
Form #
Form Name
Form Type
Revision Date
DC-529
DETENTION ORDER/CAPIAS PURSUANT TO § 16.1-247(K)
Master
07/17 (p. 1)
07/16 (p. 2)
DC-530
SHELTER CARE ORDER
Master
07/96 (p. 1)
07/91 (p. 2)
DC-531
ORDER FOR INVOLUNTARY TERMINATION OF RESIDUAL PARENTAL
RIGHTS
Master
10/15 (p. 1)
10/15 (p. 2)
DC-532
CHILD PROTECTIVE ORDER – ABUSE AND NEGLECT
Master
11/16 (p. 1)
10/15 (p. 2)
10/15 (p. 3)
DC-533
ASSESSMENT/PAYMENT ORDER
Master
10/17
DC-534
ORDER FOR VOLUNTARY TERMINATION OF RESIDUAL PARENTAL
RIGHTS
Master
11/16 (p. 1)
10/15 (p. 2)
DC-535
NOTICE OF TERMINATION OF RESIDUAL PARENTAL RIGHTS
Master
06/06
DC-536
TRIAL WITHOUT A LAWYER
Master
07/02
DC-538
PLACEMENT ORDER
Master
05/08 (p. 1)
05/08 (p. 2)
DC-539
RELEASE ORDER
Master
11/07
DC-542
ORDER FOR INVESTIGATION AND REPORT
Master
10/14
DC-543
CONFIDENTIALITY NOTICE
Master
10/07
DC-544
ORDER FOR COURT-APPOINTED SPECIAL ADVOCATE (CASA)
Master
05/03
DC-545
PRELIMINARY CHILD PROTECTIVE ORDER
Master
10/15 (p. 1)
07/14 (p. 2)
04/13 (p. 3)
DC-546
CHILD PROTECTIVE ORDER
Master
10/15 (p. 1)
04/13 (p. 2)
DC-547
SUPPLEMENTAL SHEET TO CHILD PROTECTIVE ORDER
Master
07/13 (p. 1)
07/13 (p. 2)
DC-548
CHILD IN NEED OF SUPERVISION ORDER
Master
10/17 (p. 1)
10/17 (p. 2)
10/17 (p. 3)
DC-549
ORDER OF EMANCIPATION
Master
07/16 (p. 1)
07/16 (p. 2)
DC-550
PETITION REQUESTING AUTHORIZATION FOR MEDICAL TREATMENT
OF JUVENILE
Master
10/15 (p. 1)
12/99 (p. 2)
DC-551
ORDER AUTHORIZING MEDICAL TREATMENT OF JUVENILE
Master
07/92
DC-552
FOSTER CARE SERVICE PLAN TRANSMITTAL
Master
11/16 (p. 1)
11/16 (p. 2)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 16 of 21
COURT CASE FORMS – JUVENILE DC-500S
Form #
Form Name
Form Type
Revision Date
DC-553
DISPOSITIONAL ORDER FOR UNDERLYING PETITION; FOSTER CARE
PLAN
Master
07/17 (p. 1)
10/15 (p. 2)
07/17 (A-C)
07/16 (p. 3)
07/17 (p. 4)
07/16 (p. 5)
07/14 (p. 6)
DC-554
PETITION FOR FOSTER CARE REVIEW HEARING
Master
07/13 (p. 1)
07/17 (p. 2)
DC-555
FOSTER CARE REVIEW ORDER
Master
11/16 (p. 1)
07/17 (p. 2)
07/17 (p. 3)
07/17 (p. 4)
07/16 (p. 5)
DC-556
PETITION FOR PERMANENCY PLANNING HEARING
Master
07/09 (p. 1)
07/17 (p. 2)
07/17 (p. 3)
DC-557
PERMANENCY PLANNING ORDER
Master
11/16 (p. 1)
10/15 (p. 2)
07/17 (p. 3)
07/17 (p. 4)
07/17 (p. 5)
DC-558
PERMANENT FOSTER CARE PLACEMENT ORDER
Master
07/16 (p. 1)
07/02 (p. 2)
DC-559
(A-C)
SUPPLEMENT TO ORDER TRANSFERRING CUSTODY
Master
07/01 (A)
07/00 (B)
07/00 (C)
DC-560
PETITION AND ORDER FOR PARENTAL PARTICIPATION
Master
07/04 (p. 1)
07/04 (p. 2)
DC-561
ADJUDICATORY ORDER FOR ABUSE OR NEGLECT CASES
Master
11/16 (p. 1)
07/16 (p. 2)
DC-562
ORDER FOR CUSTODY TRANSFER TO AGENCY
Master
07/17 (p. 1)
07/17 (p. 2)
10/15 (p. 3)
DC-563
CHILD IN NEED OF SERVICES ORDER
Master
10/17 (p. 1)
10/17 (p. 2)
DC-564
PETITION FOR RESTORATION OF PARENTAL RIGHTS
Master
07/13 (p. 1)
07/13 (p. 2)
DC-565
NOTICE OF PRESENTATION OF DRIVER’S LICENSE
Printed
07/12
DC-566
PARENTAL PLACEMENT ORDER FOR RESTORATION OF PARENTAL
RIGHTS
Master
10/15 (p. 1)
07/13 (p. 2)
DC-567
ORDER FOR RESTORATION OF PARENTAL RIGHTS
Master
10/15 (p. 1)
07/13 (p. 2)
DC-568
JUVENILE COMMITMENT REVIEW HEARING ORDER
Master
11/06
DC-569
ADJUDICATION AND DISPOSITION ORDER – DELINQUENCY
Master
10/17 (p. 1)
10/17 (p. 2)
10/17 (p. 3)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 17 of 21
COURT CASE FORMS – JUVENILE DC-500S
Form #
Form Name
Form Type
Revision Date
DC-570
ORDER
Printed
11/16
DC-571
ASSESSMENT ORDER – JUVENILE BOOT CAMP
Master
10/15
DC-572
JUVENILE COMMITMENT ORDER
Master
07/15
DC-573
ORDER FOR CUSTODY/PARENTING TIME/VISITATION ORDER
GRANTED TO INDIVIDUAL(S)
Master
07/17 (p. 1)
07/17 (p. 2)
DC-573-S
SUPPLEMENT SHEET TO ORDER FOR CUSTODY/VISITATION
GRANTED TO INDIVIDUAL(S)
Master
06/06
DC-574
INFORMATION CONSIDERED IN CHILD CUSTODY/VISITATION
PROCEEDINGS
Master
10/12
DC-575
CONFIDENTIAL MATERIALS – JUVENILE CASE APPEAL/TRANSFER
TRANSMITTAL
Master
07/14
DC-576
DRIVER’S LICENSE DENIAL ORDER (JUVENILE)/DRIVER’S LICENSE
SUSPENSION ORDER (UNDERAGE ALCOHOL VIOLATIONS)
(DC-261 is pages two and three of DC-260, DC-265, DC-279, DC-282,
DC-359, DC-576 & DC-577)
Printed
07/17 (p. 1, front)
07/10 (p. 1, reverse)
07/17 (p. 2)
07/17 (p. 3)
DC-577
DRIVER’S LICENSE SUSPENSION ORDER AND ENTRY INTO SERVICES
PROGRAM (JUVENILE)
(DC-261 is pages two and three of DC-260, DC-265, DC-279, DC-282,
DC-359, DC-576 & DC-577)
Printed
07/17 (p. 1, front)
07/10 (p. 1, reverse)
07/17 (p. 2)
07/17 (p. 3)
DC-578
RESTRICTED DRIVER’S LICENSE
Printed
10/15
DC-580
NOTICE OF APPEAL
Master
11/16
DC-581
NOTICE OF APPEAL – JUVENILE CIVIL APPEALS
Master
07/08
DC-582
REQUEST FOR VIRGINIA REGISTRATION OF A CHILD CUSTODY
AND/OR VISITATION DETERMINATION FROM ANOTHER STATE
Master
09/02
DC-583
NOTICE OF REQUEST FOR VIRGINIA REGISTRATION OF A CHILD
CUSTODY AND/OR VISITATION DETERMINATION FROM ANOTHER
STATE
Master
10/12
DC-584
SUPPLEMENT TO PETITION FOR EXPEDITED ENFORCEMENT UNDER
VIRGINIA CODE § 20-146.29 OF THE UCCJEA
Master
12/01
DC-585
NOTICE TO RESPONDENT IN ENFORCEMENT PROCEEDINGS UNDER
VIRGINIA CODE § 20-146.29 OF THE UCCJEA
Master
12/01
DC-586
EX PARTE ORDER TO TAKE PHYSICAL CUSTODY OF A CHILD
Master
10/13
DC-587
MOTION AND ORDER FOR EXPUNGEMENT AND DESTRUCTION OF
JUVENILE RECORDS
Printed
11/07
DC-588
NOTICE OF EXPUNGEMENT RIGHTS
Master
07/14
DC-592
EMERGENCY CUSTODY ORDER – JUVENILE
Master
07/14 (p. 1)
07/16 (p. 2)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 18 of 21
COURT CASE FORMS – JUVENILE DC-500S
Form #
Form Name
Form Type
Revision Date
DC-594
TEMPORARY DETENTION ORDER – JUDGE (JUVENILE)
Printed
07/10 (front)
07/16 (reverse)
DC-595
PETITION FOR APPROVAL OF VOLUNTARY CONTINUING SERVICES
AND SUPPORT
Master
07/16
DC-596
ORDER APPROVING VOLUNTARY CONTINUING SERVICES AND
SUPPORT
Master
11/16
DC-597
ORDER FOR INPATIENT TREATMENT – ADMISSION BY PARENTAL
CONSENT
Master
10/15 (p. 1)
07/16 (p. 2)
DC-598
ORDER FOR INVOLUNTARY COMMITMENT FOR INPATIENT
TREATMENT – JUVENILE
Master
10/15 (p. 1)
11/10 (p. 2)
07/16 (p. 3)
DC-599
ORDER FOR INVOLUNTARY ADMISSION TO MANDATORY
OUTPATIENT TREATMENT – JUVENILE
Master
10/15 (p. 1)
07/10 (p. 2)
07/16 (p. 3)
COURT CASE FORMS – MENTAL HEALTH (JUVENILE) DC-5000S
Form #
Form Name
Form Type
Revision Date
DC-5005
MOTION FOR REVIEW OF ORDER FOR MANDATORY OUTPATIENT
TREATMENT
Master
07/09 (p. 1)
07/09 (p. 2)
DC-5007
ORDER – REVIEW OF ORDER FOR MANDATORY OUTPATIENT
TREATMENT
Master
11/10 (p. 1)
07/09 (p. 2)
07/16 (p. 3)
DC-5008
ORDER OF APPOINTMENT OF EVALUATOR – EVALUATION FOR
INVOLUNTARY TREATMENT
Master
07/10 (p. 1)
07/16 (p. 2)
DC-5009
NOTICE AND MANDATORY EXAMINATION ORDER
Master
07/14
DC-5015
MOTION TO CONTINUE MANDATORY OUTPATIENT TREATMENT
ORDER
Master
07/09
DC-5017
ORDER – CONTINUE MANDATORY OUTPATIENT TREATMENT
ORDER
Master
07/09 (p. 1)
11/10 (p. 2)
07/16 (p. 3)
DC-5020
TRACKING DOCUMENT FOR SENDING OR RECEIVING MANDATORY
OUTPATIENT TREATMENT ORDER UPON ENTRY
Master
10/14
DC-5022
TRACKING DOCUMENT FOR SENDING OR RECEIVING MANDATORY
OUTPATIENT TREATMENT ORDER UPON TRANSFER
Master
10/14
DC-5024
ORDER – TRANSFER OF JURISDICTION PURSUANT TO VIRGINIA
CODE § 16.1-345.2 G
Master
10/14
COURT CASE FORMS – DOMESTIC RELATIONS DC-600S
Form #
Form Name
Form Type
Revision Date
DC-601
NOTICE – ADMINISTRATIVE SUPPORT DECISION APPEAL
Master
10/02
DC-602
NOTICE OF APPEAL – SUPPORT PROCEEDINGS
Master
07/16 (p. 1)
07/08 (p. 2)
DC-603
NOTICE OF INFORMATION REQUIRED IN CHILD/SPOUSAL
SUPPORT PROCEEDINGS
Master
10/12
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 19 of 21
COURT CASE FORMS – DOMESTIC RELATIONS DC-600S
Form #
Form Name
Form Type
Revision Date
DC-604
ORDER OF REFERRAL AND MEDIATOR APPOINTMENT FORM –
CUSTODY, VISITATION AND SUPPORT CASES
Master
07/16 (p. 1)
07/16 (p. 2)
DC-605
ORDER OF REFERRAL TO PARENT EDUCATION SEMINAR
Master
10/12
DC-606
FINANCIAL STATEMENT FOR APPLICATION TO PROCEED IN
CUSTODY/VISITATION CASE WITHOUT FILING FEES OR
FOR ASSESSMENT OF GUARDIAN AD LITEM COSTS
Master
07/17
DC-610
PETITION FOR SUPPORT (CIVIL)
Master
07/10 (p. 1)
07/15 (p. 2)
DC-611
PETITION FOR PROTECTIVE ORDER – FAMILY ABUSE
Master
07/14 (p. 1)
04/13 (p. 2)
DC-612
DESERTION/NON-SUPPORT PETITION (CRIMINAL)
Master
07/97 (p. 1)
07/15 (p. 2)
DC-614
AFFIDAVIT – DESERTION AND NON-SUPPORT
Master
04/80
DC-615
RESPONDENT’S REQUEST FOR INCOME DEDUCTION ORDER
Master
07/98
DC-616
ORDER OF TRANSFER
Master
10/15
DC-617
MOTION AND NOTICE OF PROPOSED INCOME DEDUCTION
ORDER FOR SUPPORT
Master
12/98 (p. 1)
04/06 (p. 2)
DC-618
REQUEST FOR CONFIDENTIALITY – CIVIL
Master
07/05
DC-619
EXEMPLIFICATION OF RECORD
Master
11/06
DC-620
AFFIDAVIT (UNIFORM CHILD CUSTODY JURISDICTION AND
ENFORCEMENT ACT)
Printed
05/08 (front)
11/96 (reverse)
DC-621
NON-DISCLOSURE ADDENDUM
Printed
07/09
DC-622
SEALED DOCUMENTS
Envelope
05/05
DC-623
MOTION FOR GENETIC TESTING
Master
12/01 (p. 1)
12/01 (p. 2)
DC-624
PARENTAGE TEST ORDER
Printed
12/01
DC-625
MOTION AND NOTICE AND JUDGMENT FOR ARREARAGES
Master
07/05 (p. 1)
06/06 (p. 2)
DC-626
EMERGENCY PROTECTIVE ORDER – FAMILY ABUSE
Printed
07/16 (p. 1, front)
07/16 (p. 1 & 4, reverse)
07/16 (p. 2 & 3, reverse)
DC-627
PRELIMINARY PROTECTIVE ORDER – FAMILY ABUSE
Master
10/11 (p. 1)
07/14 (p. 2)
04/13 (p. 3)
DC-628
ORDER OF SUPPORT (CIVIL)
Printed
07/15 (p. 1)
07/16 (p. 2)
07/14 (p. 3)
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 20 of 21
COURT CASE FORMS – DOMESTIC RELATIONS DC-600S
Form #
Form Name
Form Type
Revision Date
DC-629
ORDER OF SUPPORT (CRIMINAL)
Master
07/15 (p. 1)
07/15 (p. 2)
07/10 (p. 3)
DC-630
MOTION TO AMEND OR REVIEW ORDER
Printed
05/05 (front)
10/13 (reverse)
DC-631
MEDIATION SUPPORT AGREEMENT
Master
07/15 (p. 1)
07/16 (p. 2)
10/13 (p. 3)
DC-632
ORDER OF SUPPORT (CIVIL) FOR MEDIATION SUPPORT
AGREEMENT
Master
10/12
DC-633
NOTICE OF ISSUANCE OF EMERGENCY PROTECTIVE ORDER –
FAMILY ABUSE
Printed
11/16 (p. 1, front)
11/16 (p. 1&4, reverse)
11/16 (p. 2&3, reverse)
DC-634
MOTION TO WITHDRAW CONSENT TO DEFERRAL OF
PROCEEDINGS PURSUANT TO VA. CODE § 18.2-57.3(B)
Master
10/17
DC-635
MOTION FOR SHOW CAUSE SUMMONS OR CAPIAS
Printed
10/15
DC-637
CHILD SUPPORT GUIDELINES WORKSHEET
Master
10/15 (p. 1)
07/15 (p. 2)
DC-638
CHILD SUPPORT GUIDELINES WORKSHEET SPLIT CUSTODY
Master
10/15 (p. 1)
07/15 (p. 2)
DC-639
CHILD SUPPORT GUIDELINES EXCEPTION SUPPLEMENT TO
ORDER FOR SUPPORT
Master
07/13
DC-640
CHILD SUPPORT GUIDELINES WORKSHEET – SHARED
CUSTODY
Master
10/15 (p. 1)
07/17 (p. 2)
DC-641
PARENTAGE SUPPLEMENT TO PETITION
Master
10/17
DC-644
ORDER DETERMINING PARENTAGE
Printed
10/11 (front)
02/04 (reverse)
DC-645
INCOME WITHHOLDING FOR SUPPORT
Master
10/14 (p. 1)
10/14 (p. 2)
10/14 (p. 3)
10/14 (p. 4)
10/14 (p. 5)
10/14 (p. 6)
10/14 (p. 7)
DC-650
PROTECTIVE ORDER – FAMILY ABUSE
Master
07/16 (p. 1)
07/16 (p. 2)
07/14 (p. 3)
11/10 (p. 4)
DC-652
ORDER DISSOLVING PROTECTIVE ORDER
Master
10/15 (p. 1)
10/11 (p. 2)
DC-653
SUPPLEMENTAL SHEET TO PROTECTIVE ORDER
Master
10/08
DC-660
PERFORMANCE BOND
Master
09/02
DC-670
PETITION FOR SUSPENSION OF PROFESSIONAL OR OTHER
LICENSE
Master
07/16
COMMONWEALTH OF VIRGINIA DISTRICT COURT FORMS LISTING
Revised 10/2017 Page 21 of 21
COURT CASE FORMS – DOMESTIC RELATIONS DC-600S
Form #
Form Name
Form Type
Revision Date
DC-671
ORDER FOR SUSPENSION OF PROFESSIONAL OR OTHER
LICENSE
Master
10/02
DC-672
CERTIFICATE OF COMPLIANCE FOR REINSTATEMENT OF
PROFESSIONAL OR OTHER LICENSE
Master
10/02
DC-680
CONSENT FOR ADOPTION
Master
07/08
DC-684
FILING OF FOREIGN PROTECTIVE ORDER
Master
10/15
DC-685
REQUEST FOR VIRGINIA REGISTRATION OF NON-VIRGINIA
SUPPORT ORDER
Master
04/15 (p. 1)
04/15 (p. 2)
DC-686
NOTICE OF REGISTRATION OF NON-VIRGINIA SUPPORT
ORDER
Master
04/15 (p. 1)
04/15 (p. 2)
COURT CASE FORMS – MAGISTRATE DC-800S
Form #
Form Name
Form Type
Revision Date
DC-801
ZONING ORDINANCE INSPECTION AFFIDAVIT AND WARRANT
Master
07/17 (p. 1)
07/14 (p. 2)
DC-890
MAGISTRATE LOG
Printed
09/92
DC-892
MAGISTRATE MONTHLY SUMMARY REPORT
Printed
05/00
DC-894
TRANSMITTAL SETTLEMENT CARDS
Printed
07/88
DC-894(A)
TEMPORARY DETENTION ORDER – MAGISTRATE
Master
07/16 (p. 1)
07/16 (p. 2)
DC-895
TEMPORARY DETENTION ORDER – MAGISTRATE (JUVENILE)
Master
07/10 (p. 1)
07/16 (p. 2)
CIRCUIT COURT FORMS USED IN DISTRICT COURT
Form #
Form Name
Form Type
Revision Date
CC-1390
ORDER FOR DNA OR HIV TESTING AND/OR FOR PREPARATION OF
REPORTS TO CENTRAL CRIMINAL RECORDS EXCHANGE
Printed
07/07
CC-1414
PETITION FOR PROCEEDING IN CIVIL CASE WITHOUT PAYMENT OF
FEES OR COSTS
Master
10/14
CC-1433
NOTICE OF COMMENCEMENT OF ACTION AND REQUEST FOR
WAIVER OF SERVICE OF PROCESS
Master
07/11

Navigation menu