ALASKA COURT SYSTEM CERTIFICATE OF FACTS (Relative to a civil judgment arising out of a motor vehicle accident. AS 28.20.280) I certify that a civil judgment arising out of a motor vehicle accident was entered against the debtor as described below: Debtor's Name Debtor's Address Date of Judgment Debtor's Date of Birth (If Available) Case Number Amount of Judgment $ Date of Accident State Debtor's Driver's License No. (If Available) A satisfaction of judgment has not been filed as of the date stated below. The time for appeal has passed, and no appeal has been filed or the debtor has lost the appeal. NOTICE TO DEPARTMENT OF ADMINISTRATION: If further information is needed about the above-named judgment debtor or about this case, please contact: Date Signature of Creditor or Creditor's Attorney Type or Print Name Mailing Address City Daytime Telephone NOTE: This form is not valid without court signature. Creditor must obtain a certified copy of the judgment from the court and submit it along with this certificate to the court for processing. Clerk's Certificate of Distribution I certify that this Certificate of Facts was distributed as follows: 1. Original to court file. 2. Copy with certified copy of judgment to Department of Administration, Financial Responsibility Section, P.O. Box 110221, Juneau, Alaska 99811. 3. Copy to plaintiff. 4. Copy to defendant. Date CIV-405 (1/16)(cs) CERTIFICATE OF FACTS MOTOR VEHICLE ACCIDENTS State ZIP Clerk of Court/Deputy Clerk/Magistrate Judge AS 28.20.280 AS 28.20.270 AS 28.20.630(1) American LegalNet, Inc. www.FormsWorkFlow.com