FORM CC-1512 (MASTER, PAGE ONE OF TWO) 07/19 MEMORANDUM FOR MECHANIC222S LIEN CLAIMED BY GENERAL CONTRACTOR UNDER VIRGINIA CODE 247 43-5 ..................................................................................................................................................................................................................... Circuit Court ...................................................................................................................................................................................................................................................... ADDRESS TELEPHONE NUMBER .................................................................................................................. or .................................................................................................................. TAX MAP REFERENCE PARCEL IDENTIFICATION NUMBER .................................................................................................................. .................................................................................................................. NAME OF OWNER NAME OF CLAIMANT .................................................................................................................. .................................................................................................................. ADDRESS OF OWNER ADDRESS OF CLAIMANT .................................................................................................................. .................................................................................................................. .................................................................................................................. 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 amount is claimed: ........................................................................................... DATE American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com