                                 CODE OF VIRGINIA

SUFFICIENCY OF MEMORANDUM AND AFFIDAVIT REQUIRED BY § 43-4 (§ 43-5)

The memorandum and affidavit required by § 43-4 shall be sufficient if
substantially in form and effect as follows:
		Memorandum for Mechanic&#8217;s Lien Claimed by General Contractor.
		Name of owner:
___________________________________________________________________________
		Address of owner:
___________________________________________________________________________
		Name of claimant:
___________________________________________________________________________
		Address of claimant:
___________________________________________________________________________
		Contractor license or certificate number of claimant
		(if applicable):
___________________________________________________________________________
		Issuance date of license or certificate
		(if applicable):
___________________________________________________________________________
		Expiration date of license or certificate
		(if applicable):
___________________________________________________________________________
		If 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.

1. Type of materials or services furnished:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
			___________________________________________________________________________
			___________________________________________________________________________

2. Amount claimed:  $
___________________________________________________________________________
			If any part of the Amount claimed is not due as of the date of this
mechanic&#8217;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:
___________________________________________________________________________

3. Type of structure on which work done or materials furnished:
___________________________________________________________________________
			___________________________________________________________________________

4. Brief description and location of real property:
			___________________________________________________________________________

5. Date from which interest on the above amount is claimed:
			Date: _______________________
			It is the intent of the claimant to claim the benefit of a lien.
			The undersigned hereby certifies that he has mailed a copy of this memorandum
of lien to the owner of the property at the owner&#8217;s last known address:
&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;.
(address), on &#8230;&#8230;..   (date of mailing).
			___________________________________________________________________________ 
(Name of claimant).
			Affidavit.
			State of Virginia,
			County (or city) of &#8230;&#8230;&#8230;&#8230;&#8230;&#8230;,  to wit:
			I, _______________________  (notary or other officer) for the county (or
city) aforesaid, do certify that
&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;.  claimant, or
&#8230;&#8230;&#8230;&#8230;&#8230;., agent for claimant, this day made oath
before me in my county (or city) aforesaid that
&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230; (the owner) is justly indebted
to claimant in the sum of &#8230;&#8230;&#8230;&#8230;.. dollars, for the
consideration stated in the foregoing memorandum, and that the same is payable
as therein stated.
			Given under my hand this the &#8230;&#8230;.. day of
&#8230;&#8230;&#8230;&#8230;&#8230;.., 20&#8230;.
			___________________________________________________________________________
(Notary Public or Magistrate, et cetera.)

HISTORY: Code 1919, § 6427; 1940, p. 402; 1968, c. 568; 2007, c. 504; 2013, c.
293; 2019, c. 243.