The memorandum and affidavit required by § 43-4 shall be sufficient if substantially in form and effect as follows:\nMemorandum for Mechanic's Lien Claimed by General Contractor.\nName of owner: ___________________________________________________________________________\nAddress of owner: ___________________________________________________________________________\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 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. tor 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___________________________________________________________________________\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: 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. Brief description and location of real property:\n___________________________________________________________________________\n5. Date from which interest on the above amount is claimed:\nDate: _______________________\nIt is the intent of the claimant to claim the benefit of a lien.\nThe undersigned hereby certifies that he has mailed a copy of this memorandum of lien to the owner of the property at the owner's last known address: .................................. (address), on ........ (date of mailing).\n___________________________________________________________________________ (Name of claimant).\nAffidavit.\nState of Virginia,\nCounty (or city) of .................., to wit:\nI, _______________________ (notary or other officer) for the county (or city) aforesaid, do certify that ...................... .\nState of Virginia,\nCounty (or city) of .................., to wit:\nI, _______________________ (notary or other officer) for the county (or city) aforesaid, do certify that ...................... claimant, or ................, agent for claimant, this day made oath before me in my county (or city) aforesaid that ..................... (the owner) 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 Magistrate, et cetera.)\nCode 1919, § 6427; 1940, p. 402; 1968, c. 568; 2007, c. 504; 2013, c. 293; 2019, c. 243.
Virginia Legal Code