Fill and Sign the Va Mechanic Lien Form

MEMORANDUM FOR MECHANIC’S LIEN CLAIMED BY GENERAL CONTRACTOR UNDER VIRGINIA CODE § 43-5       Circuit Court             ADDRESS TELEPHONE NUMBER       or       TAX MAP REFERENCE NUMBER PARCEL IDENTIFICATION NUMBER       NAME OF OWNER       ADDRESS OF OWNER       NAME OF GENERAL CONTRACTOR (if any)       NAME OF CLAIMANT       ADDRESS OF CLAIMANT 1. Type of materials or services furnished:       2. Amount claimed: $       . Type of structure on which work done or materials furnished:       Brief description and location of rea l property:       Date from which interest on the above account is claimed:       It is the intent of the claimant to claim the benefit of a lien. The undersigned hereby certifies to having mailed a copy of this memorandum of lien to the owner of the property at the property owner’s last known address,       .Return To:    GPN #      Prepared By:     ADDRESS       on       DATE OF MAILING       DATE SIGNATURE OF CLAIMANT AFFIDAVIT State of Virginia, County or City of       , to wit: I,       of 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       , 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. Given under my hand this       day of       , 20       [ ] CLERK [ ] DEPUTY CLERK [ ] NOTARY Registration No.       My commission expires:       This instrument was admitted to record       at       DATE TIME , Clerk by , Deputy Clerk FORM CC-1512 (MASTER, PAGE TWO OF TWO) 7/07