CERTIFICATION OF MECHANIC'S LIEN AGENT - VIRGINIA
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: ________________________________________________________
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.
Mechanic's Lien Agent Address
and Telephone Number: ______________________________________ ______________________________________ ______________________________________ (Telephone) ______________________________________ (Facsimile)
STATE OF VIRGINIA
COUNTY/CITY OF _____________________
Acknowledged before me this _____ day of ____________, 20____, by
My Commission Expires: _________________
No guidelines are available for this form at this time.