Whenever judgments are docketed in the judgment lien book in the office of the clerk of the circuit court and are recorded by a procedural micrographic process as provided in § 17.1-240, or by any other method or process which renders impractical or impossible the subsequent entry of notations upon the docketed judgment, an appropriate certificate of assignment, release, partial release, certified copy of any order, or other separate instrument setting forth the necessary information as provided in this section shall be recorded and indexed according to law. Such instrument shall conform substantially with the following form:

ORIGINAL BOOK # _____ PAGE _____ (or instrument no)

ORIGINAL DATE DOCKETED: ____________________

TYPE OF FILING (Check One)

( ) Assignment

( ) Release

( ) Partial Release

( ) Credit(s)

( ) Additional Debtor(s)

( ) New Name of Debtor

Date of Judgment: ____________________

Amount of Judgment: ____________________

Plaintiff(s): ________________________________________

Defendant(s): ________________________________________

Assignee (If assignment): ________________________________________

Payments (If credits): AMOUNT __________ DATE PAID __________

(Complete below if additional debtor or change of name of debtor)

Debtor: ________________________________________

Social Security Number of Debtor (Last Four Digits) (If known): __________

Given under my hand this __________ day of __________, __________

________________________________________(Plaintiff) (Attorney for Plaintiff)(Authorized Agent for Plaintiff)

Any judgment creditor who knowingly gives false information upon such certificate made under this section shall be guilty of a Class 1 misdemeanor.