FORM CC-1514 (MASTER, PAGE ONE OF TWO) 07/19 MEMORANDUM FOR MECHANIC222S LIEN CLAIMED BY SUB-SUBCONTRACTOR UNDER VIRGINIA CODE 247 43-9 ....................................................................................................................................................................................................................... Circuit Court ...................................................................................................................................................................................................................................................... ADDRESSTELEPHONE NUMBER .......................................................................................................................... or ............................................................................................................... TAX MAP REFERENCE NUMBER PARCEL IDENTIFICATION NUMBER ................................................................................................................. .................................................................................................................. NAME OF OWNER NAME OF CLAIMANT ................................................................................................................. .................................................................................................................. ADDRESS OF OWNER ADDRESS OF CLAIMANT ................................................................................................................. .................................................................................................................. ................................................................................................................. .................................................................................................................. NAME OF GENERAL CONTRACTOR (if any) AND SUBCONTRACTOR CONTRACTOR LICENSE OR CERTIFICATE NO. 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. 1.Type of materials or services furnished: ..................................................................................................................................................................................................................................... 2.Amount claimed: $ ..........................................................................................................................................................................................If any part of the Amount claimed is not due as of the date of this mechanic222s 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: ..................................................................................................................................................................................................................................... 3. Type of structure on which work done or materials furnished: ..................................................................................................................................................................................................................................... 4. Brief description and location of real property: . ..................................................................................................................................................................................................................................... 5.Date from which interest on the above account is claimed: ..................................................................................................... American LegalNet, Inc. www.FormsWorkFlow.com It is the intent of the claimant to claim the benefit of a lien. .......................................................................................... DATE SIGNATURE OF CLAIMANT AFFIDAVIT State of Virginia, County or City of ..................................................................................................................................................................................., to wit: I, ................................................................................................................................... of the county (or city) aforesaid, do certify that NOTARY OR OTHER OFFICER ..............................................................................................................., 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 .............................................................. day of ......................................................, 20 ................... [ ] CLERK [ ] DEPUTY CLERK [ ] NOTARY Registration No. .......................................... My commission expires: .......................................... . 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 said ........................................................................................ (describe structure, whether dwelling, store or etc.,) which he has contracted to construct (or remove, etc.,) for you or on property owned by you in the county or city of ........................................................ and that I have duly recorded a mechanic222s lien for the same. Given under my hand this ................................................... day of ......................................................, 20 .................................. SIGNATURE OF SUB-SUBCONTRACTOR This instrument was admitted to record ............................................................. at ........................................................................ DATE TIME ............................................................................................................, Clerk by ...................................................................................., Deputy Clerk FORM CC-1514 (MASTER, PAGE TWO OF TWO) 10/13 American LegalNet, Inc. www.FormsWorkFlow.com