The memorandum, affidavit and notice required by § 43-9 shall be sufficient if substantially in form and effect as follows:\nMemorandum for Mechanic's Lien Claimed by Sub-subcontractor.\nName of owner: ___________________________________________________________________________\nAddress of owner: ___________________________________________________________________________\nName of general contractor (if any) and subcontractor:\n___________________________________________________________________________\nName of claimant: ___________________________________________________________________________\nAddress of claimant: ___________________________________________________________________________\nContractor license or certificate number of claimant\n(if applicable): ___________________________________________________________________________\nIssuance date of license or certificate\n(if applicable): ___________________________________________________________________________\nExpiration date of license or certificate\n(if applicable): ___________________________________________________________________________\nIf no contractor license or certificate number is included, the claimant date of license or certificate\n(if applicable): ___________________________________________________________________________\nIf no contractor license or certificate number is included, the claimant certifies that such a valid license or certificate is not required by law for the work done for which the benefit of a lien is claimed.\n1. Type of materials or services furnished: ___________________________________________________________________________\n___________________________________________________________________________\n2. Amount claimed: $ ___________________________________________________________________________\nIf any part of the Amount claimed is not due as of the date of this mechanic's lien, identify the date or event upon which it will be due, and the sum(s) to which the due date(s) or event(s) apply: ___________________________________________________________________________\n3. Type of structure on which work done or materials furnished: ___________________________________________________________________________\n___________________________________________________________________________\n4. on which work done or materials furnished: ___________________________________________________________________________\n___________________________________________________________________________\n4. Brief description and location of real property: ___________________________________________________________________________\n___________________________________________________________________________\n5. Date from which interest on above amount is claimed:\nDate: ____________________________\nIt is the intent of the claimant to claim the benefit of a lien.\n____________________________ (Name of claimant).\n______________ (Signature of claimant or agent for claimant).\nAffidavit.\nState of Virginia,\nCounty (or city) of ________________________, to wit:\nI, ___________________________________________________________________________ (notary or other officer) for the county (or city)\naforesaid do certify that ___________________________________________ claimant, or ___________________________________________, agent for claimant, this day made oath before me in my county (or city) aforesaid that _______________ is justly indebted to claimant in the sum of __________ dollars for the _______________________, agent for claimant, this day made oath before me in my county (or city) aforesaid that _______________ is justly indebted to claimant in the sum of __________ dollars for the consideration stated in the foregoing memorandum, and that the same is payable as therein stated.\nGiven under my hand this the ................ day of ..............., 20....\n________________________________________ (Notary Public or\nMagistrate, et cetera.)\nNotice.\nTo __________________________ (owner) and __________________________ (general contractor):\nYou are hereby notified that ___________________________________________________________________________ , a subcontractor under you,\nsaid ___________________________________________________________________________ (general contractor) for the construction (or removal,\netc.,) of a ___________________________________________________________________________ (describe structure) for you, or on property owned by\nyou, said ___________________________________________________________________________ (owner) is indebted to me in the sum of .............\n................. dollars ($ ______________) with interest thereon from the .... _______________________________________________________________ (owner) is indebted to me in the sum of .............\n................. dollars ($ ______________) with interest thereon from the .... day of ......., 20..., for work done (or materials furnished) in and about the construction (or removal, etc.,) of _________________________ (naming structure), situate in the county (or city) of _______________ Virginia, and that I have duly recorded a mechanic's lien for the same.\nGiven under my hand this the .................. day of ..............., 20.......\n__________________________________________________ (Sub-subcontractor).\nCode 1919, § 6429; 1968, c. 568; 1984, c. 647; 2007, c. 504; 2013, c. 293; 2019, c. 243.
Virginia Legal Code