CONFESSION OF JUDGMENT/ CERTIFICATE OF CLERK Va. Code §§ 8.01-431, 8.01-433, 8.01-436, 8.01-437, 17.1-124 Case No. ............................................................................... In the Clerk's Office of the Circuit Court of ................................................................................................................................................. , Virginia CONFESSION OF JUDGMENT CREDITOR(S): ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... ..................................................................................................................... DEBTOR(S): v .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. I/we, the above-named debtor(s), acknowledge myself/ourselves, to be justly indebted to, and do confess judgment in favor of, the above-named creditor(s) in the sum of $ ..................... (.................................................................................................................... dollars) together with interest thereon at the rate of .............................. % from .................... until paid and cost of this proceeding (including the attorney's fees and collection fees provided for in the instrument on which the proceeding is based) hereby waiving my/our homestead exemptions as to the same, provided the instrument on which the proceeding is based carries such homestead waiver. Given under my/our hand(s) this day. ........................................................................ DATE _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ (seal) (seal) (seal) (seal) (seal) COSTS STATEMENT $ $ $ $ $ $ $ $ $ $ ..................................... ..................................... ..................................... ..................................... ..................................... ..................................... ..................................... ..................................... ..................................... Writ Tax Clerk's Fees Docketing Fee Tech Trust Fund Fee Sheriff's Fee Registered/Certified Mail by _______________________________________________________________________ ATTORNEY IN FACT [ ] Power of Attorney in Debt Instrument [ ] Separate Power of Attorney Document [ ] Appointment of Substitute Attorney-in-fact recorded on ................................................................. DATE Legal Aid/Indigent Defense Fee Courthouse Construction Fee Law Lib/Courthouse Maintenance Fee Court Technology Fee Instrument No. .......................................................... .............................................. ..................................... Deed Book/Page No. CERTIFICATE OF CLERK The foregoing judgment was confessed before me in my office on the date and time shown below and entered of record, also as shown below: .............................................................................................................................. DATE AND TIME OF CONFESSION Order Book No. ........................................ Page No. ............................ Instrument No. ............................................................................................................................................................................................................................. Attached to this Judgment of Confession are: [ ] Debt instrument containing a Power of Attorney [ ] Separate Power of Attorney [ ] Separate Debt Instrument __________________________________________________ , Clerk by ______________________________________________________ DEPUTY CLERK SEE NOTICE TO DEBTOR ON PAGE TWO OF TWO FORM CC-1420 (MASTER, PAGE ONE OF TWO) 07/12 American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO DEBTOR: § 8.01-433. Setting aside judgments confessed under § 8.01-432. ­ Any judgment confessed under the provisions of §8.01-432 may be set aside or reduced upon motion of the judgment debtor made within twenty-one days following notice to him that such judgment has been entered against him, and after twenty-one days notice to the judgment creditor or creditors for whom the judgment was confessed, on any ground which would have been an adequate defense or setoff in an action at law instituted upon the judgment creditor's note, bond or other evidence of debt upon which such judgment was confessed. Whenever any such judgment is set aside or modified the case shall be placed on the trial docket of the court, and the proceedings thereon shall thereafter be the same as if an action at law had been instituted upon the bond, note or other evidence of debt upon which judgment was confessed. After such case is so docketed the court shall make such order as to the pleadings, future proceedings and costs as to the court may seem just. FORM CC-1420 (MASTER, PAGE TWO OF TWO) 01/06 American LegalNet, Inc. www.FormsWorkFlow.com