On the presentation of any such power of attorney as is mentioned in § 8.01-435 by any of the persons therein named as attorney-in-fact, or on the personal appearance of the debtor and the expression by him of his desire to confess such judgment, the clerk of the court mentioned in such power of attorney, or before whom such debtor shall so appear, shall draw and require the attorney-in-fact so appearing, or the debtor, as the case may be, to sign a confession of judgment, which shall be in form substantially as follows:
"Virginia: In the clerk's office of the __________ court of the __________ of __________, I, (or we) A.B., (or A.B. and C.D., etc.) hereby acknowledged myself (or ourselves) to be justly indebted to, and do hereby confess judgment in favor of (name of creditor) in the sum of __________ dollars ($_____) with interest thereon from the __________ day of __________, two thousand __________, until paid, and the cost of this proceeding (including the attorney's fees and collection fees provided for in the instrument on which the proceeding is based) hereby waiving the benefit of my (or our) homestead exemptions as to the same, provided the instrument on which the proceeding is based carries such homestead waiver.
Given under my (or our) hand, this __________ day of __________, two thousand and __________
(Signatures)
or, if by an attorney-in-fact, signatures and seals of debtors,
By ____________________
his (or their) attorney-in-fact."
Code 1950, § 8-360; 1977, c. 617.