CERTIFICATION OF MECHANIC'S LIEN AGENT
The undersigned hereby certifies as follows: ______________________________________________________ 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 §43-1 of the Code of Virginia (1950, as amended) with respect to:
The following items are attached hereto:
A. A copy of Building Permit # issued in connection with
improvements to the property, as furnished by the owner;
B. 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 §43-4.01
of the Code of Virginia or not.
Mechanic’s Lien Agent
Mechanic's Lien Agent Address and Telephone Numbers:
Telephone: ______________________ Facsimile: _______________ Email: __________________________
STATE OF VIRGINIA, CITY/COUNTY OF ______________________; to-wit:
Acknowledged before me this _______ day of ___________________________, 201___, by _____________
__________________________________________ Notary Public
My Commission Expires:________________________.
No guidelines are available for this form at this time.