RETURN COMPLETED FORM TO: PENNSYLVANIA DEPT. OF TRANS.

BUREAU OF DRIVER LICENSING

P.O. BOX 60037

HARRISBURG, PA. 17106-0037

CERTIFICATION OF MOTOR VEHICLE JUDGMENT	DATE
COUNTY	COUNTY NO.
NO	TERM	2
(PLEASE TYPE)

TO THE SECRETARY OF TRANSPORTATION

This is to certify that on a judgment for $Amount plus $Cost was entered against the following:

JUDGMENT DEBTOR

Name
Address
City
Date of Birth
Operator Number
Date of Accident
Insurance Co. Claim Number
(If applicable)

JUDGMENT CREDITOR
ATTORNEY FOR THE JUDGMENT CREDITOR

(if applicable)
(NAME)
(NAME)
(STREET ADDRESS)
(STREET ADDRESS)
CITY
STATE
ZIP
CITY
STATE
ZIP
(TELEPHONE NO.)
(TELEPHONE NO.)

THE ABOVE MENTIONED JUDGMENT AROSE FROM A MOTOR VEHICLE ACCIDENT. SIXTY DAYS HAVE ELAPSED SINCE THE ENTRY OF SAID JUDGMENT, AND THE SAME HAS NOT BEEN SATISFIED OF RECORD AND NO APPEAL HAS BEEN TAKEN THEREFROM.

IN WITNESS WHEREOF, I have hereunto affixed my hand and seal of the court this

Day of __________________________2_________ _________________________________________

(SIGNATURE OF CLERK OR JUDGE OF THE

COURT IN WHICH THE JUDGMENT WAS RENDERED)

________________________________________

(TYPE OR PRINT NAME)

(REV. 4/00)

PENNSYLVANIA DEPT

JENNIFER BENKOVIC

2008-12-09

Wotring-ra