Va. Code § 43-10
The memorandum, affidavit and notice required by § 43-9 shall be sufficient if substantially in form and effect as follows:
Memorandum for Mechanic's Lien Claimed by Sub-subcontractor.
Name of owner: ___________________________________________________________________________
Address of owner: ___________________________________________________________________________
Name of general contractor (if any) and subcontractor:
___________________________________________________________________________
Name of claimant: ___________________________________________________________________________
Address of claimant: ___________________________________________________________________________
Contractor license or certificate number of claimant
(if applicable): ___________________________________________________________________________
Issuance date of license or certificate
(if applicable): ___________________________________________________________________________
Expiration date of license or certificate
(if applicable): ___________________________________________________________________________
If no contractor license or certificate number is included, the claimant certifies that such a valid license or certificate is not required by law for the work done for which the benefit of a lien is claimed.
___________________________________________________________________________
If any part of the Amount claimed is not due as of the date of this mechanic's lien, identify the date or event upon which it will be due, and the sum(s) to which the due date(s) or event(s) apply: ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Date: ____________________________
It is the intent of the claimant to claim the benefit of a lien.
____________________________ (Name of claimant).
______________ (Signature of claimant or agent for claimant).
Affidavit.
State of Virginia,
County (or city) of ________________________, to wit:
I, ___________________________________________________________________________ (notary or other officer) for 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 _______________ 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 the ................ day of ..............., 20....
________________________________________ (Notary Public or
Magistrate, et cetera.)
Notice.
To __________________________ (owner) and __________________________ (general contractor):
You are hereby notified that ___________________________________________________________________________ , a subcontractor under you,
said ___________________________________________________________________________ (general contractor) for the construction (or removal,
etc.,) of a ___________________________________________________________________________ (describe structure) for you, or on property owned by
you, said ___________________________________________________________________________ (owner) is indebted to me in the sum of .............
................. dollars ($ ______________) with interest thereon from the .... day of ......., 20..., for work done (or materials furnished) in and about the construction (or removal, etc.,) of _________________________ (naming structure), situate in the county (or city) of _______________ Virginia, and that I have duly recorded a mechanic's lien for the same.
Given under my hand this the .................. day of ..............., 20.......
__________________________________________________ (Sub-subcontractor).
Va. Code § 43-10