VA Certification of Mechanic's Lien Agent

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:

Property Description:_______________________________________________________________________

Property Address:__________________________________________________________________________

Owner:___________________________________________________________________________________

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.

Date:_______________________                              __________________________________________
                                                                                          Mechanic’s Lien Agent

Mechanic's Lien Agent Address and Telephone Numbers:

Business Address:___________________________________________________________________________                       

Telephone:   ______________________ Facsimile: _______________ Email: __________________________

STATE OF VIRGINIA, CITY/COUNTY OF ______________________; to-wit:

Acknowledged before me this _______ day of ___________________________, 20____, by _____________

__________________________________________________________________________________________________.

                                                                                    __________________________________________                                                                                    Notary Public

                                                                                    My Commission Expires:________________________.