VA Certification of Mechanic's Lien Agent 1995


The undersigned hereby certifies as follows:

1. __________________________________ has been designated in writing as the Mechanic's Lien Agent and has consented to such designation in writing in accordance with the provisions of Section 43-1 of the Code of Virginia (1950, as amended) with respect to:

Property Description: ______________________________________________________

Property Address: ________________________________________________________

Owner: _________________________________________________________________

2. The following items are attached hereto:

A. A certified copy of building permit # _____________ issued in connection with improvements to the property. (with first certificate only)

B. Acceptance of Appointment as Mechanic's Lien Agent (with first certificate only)

C. A complete listing of all names, addresses and telephone numbers of parties that have furnished the undersigned with notice as of the date hereof, that they seek payment for labor performed on, or materials furnished to, the Property.

D. Copies of all notices received by the undersigned whether the notices comply with Section 43-4.01 of the Code of Virginia, or not.

Date: _________________________________

Mechanic's Lien Agent Address

and Telephone Number: ______________________________________ ______________________________________ ______________________________________ (Telephone) ______________________________________ (Facsimile)


COUNTY/CITY OF _____________________

Acknowledged before me this _____ day of ____________, 20____, by


Notary Public

My Commission Expires: _________________

No guidelines are available for this form at this time.