Va. Code § 43-8
The memorandum, affidavit and notice required by § 43-7 shall be sufficient if substantially in form and effect as follows:
Memorandum for Mechanic's Lien Claimed by Subcontractor.
Name of owner: ___________________________________________________________________________
Address of owner: ___________________________________________________________________________
Name of general contractor (if any): ___________________________________________________________________________
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).
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).
You are hereby notified that ____________________ (general contractor) is indebted to me in the sum of ________________ dollars ($__________) with interest thereon from the __________ day of __________, 20___, for work done (or materials furnished, as the case may be,) in and about the construction (or removal, etc.,) of a ____________________________ (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 mechanic's lien for the same.
Given under my hand this the ________________ day of ___________, 20_____.
____________________________ (Subcontractor).
Va. Code § 43-8