Fill and Sign the Virginia Lien Form

MEMORANDUM FOR MECHANIC’S LIEN CLAIMED BY SUBCONTRACTOR UNDER VIRGINIA CODE § 43-7       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: $       . 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 account is claimed:       It is the intent of the claimant to claim the benefit of a lien.       DATE SIGNATURE OF CLAIMANTReturn To:    GPN #      Prepared By:     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:       NOTICE To       , owner. You are hereby notified that       general contractor, is indebted to me in the sum of       dollars ($       ) with interest thereon from the       day of       , 20       , for work done (or materials furnished, as the case may be) in and about the construction (or removal, etc.,) of a       (describe structure, whether dwelling, store or etc.,) which he has contracted to construct (or remove, etc.,) for you or on property owned by you in the county or city of       and that I have duly recorded a mechanic’s lien for the same. Given under my hand this       day of       , 20       SIGNATURE OF SUB-SUBCONTRACTOR This instrument was admitted to record       at       DATE TIME , Clerk by , Deputy Clerk FORM CC-1513 (MASTER, PAGE TWO OF TWO) 7/07