Va. Code Ann. § 54.1-2139.1
B. Use of designated agents or representatives in a residential real estate transaction shall be disclosed in accordance with the provisions of this article. Such disclosure may be given in combination with other disclosures or provided with other information, but if so, the disclosure shall be conspicuous, printed in bold lettering, all capitals, underlined, or within a separate box. Any disclosure that complies substantially in effect with the following shall be deemed in compliance with such disclosure requirement:
DISCLOSURE OF DESIGNATED AGENTS OR REPRESENTATIVES IN A RESIDENTIAL REAL ESTATE TRANSACTION
The undersigned do hereby acknowledge disclosure that:
The licensee __________________ (Name of Broker and Firm) represents more than one party in this residential real estate transaction as indicated below:
________ Seller(s) and Buyer(s)
________ Landlord(s) and Tenant(s).
The undersigned understand that the foregoing dual agent or representative may not disclose to either client or such client's designated agent or representative any information that has been given to the dual agent or representative by the other client within the confidence and trust of the brokerage relationship except for that information which is otherwise required or permitted by Article 3 (§ 54.1-2130 et seq.) of Chapter 21 of Title 54.1 of the Code of Virginia to be disclosed.
The principal or supervising broker has assigned _________________ to act as Designated Agent or Representative (broker or salesperson) for the one party as indicated below:
[ ] Seller(s) [ ] Buyer(s) [ ] Landlord(s) [ ] Tenant(s)
As a (select one):
[ ] standard agent [ ] limited service agent [ ] independent contractor
____________________ (broker or salesperson) to act as Designated Agent or Representative for the other party as indicated below:
[ ] Seller(s) [ ] Buyer(s) [ ] Landlord(s) [ ] Tenant(s)
As a (select one):
[ ] standard agent [ ] limited service agent [ ] independent contractor
The undersigned by signing this notice do hereby acknowledge their consent to the disclosed dual representation by the licensee.
____________ _______________________
Date Name (One Party)
____________ _______________________
Date Name (One Party)
____________ _______________________
Date Name (One Party)
____________ _______________________
Date Name (One Party)
2011, c. 461; 2012, c. 750; 2016, c. 334; 2025, cc. 479, 495.