Certi037cate of Facts RE Unsatis037ed Judgment(SEE INSTRUCTIONS ON NEXT PAGE)30(Do not complete or sign until 30 days after 037nality of judgment unless the court ordered installment payments.) After completion of this form, please mail it with your nonrefundable check or money order in the amount of $20 to: DMV, Mail Station J237, P.O. Box 942884, Sacramento, CA 94284-0884. DO NOT TAKE IT TO YOUR LOCAL DEPARTMENT OF MOTOR VEHICLES.Title of Court (INCLUDE COUNTY, JUDICIAL DISTRICT OR DIVISIONCourt Code (AVAILABLE FROM COURT CLERK)STATE OFCALIFORNIAPlaintiff :Defendant :vs.Case No. :Date Filed :The undersigned Clerk/Judge of the Court hereby certi037es as follows:1. The above judgment was based on a tort claim as a result of a motor vehicle accident.2. The judgment was entered on , and became 037nal , and remained unsatis037edMONTH DAY YEAR MONTH DAY YEARfor 30 days thereafter.3. Judgment was entered against a. Bodily injury d.Costs b. Damage to property e. Loss of use c. Wrongful death f.Any other ground TOTAL 4. The court (ordered, did not order) the judgment paid in installments.(If so ordered, a certi037ed copy of such order must be attached as required by California Vehicle Code (CVC) 24716379.)DATE SIGNED XOFFICIAL TITLE The undersigned creditor/attorney hereby certi037es the following (lines 5 through 13 apply to the judgment debtor(s) only):5. The date of the accident was MONTH DAY YEARFOR DMV USE ONLY:6. Did accident occur in California? Yes No7. Was the judgment awarded in a California court? Yes No8. The vehicle involved in the accident was owned by 9. The vehicle involved in the accident was operated by 10. The ownership of the vehicle resulted in a judgment against 11. The operation of the vehicle resulted in a judgment against 12. Debtor's vehicle information (vehicle involved in the accident) LICENSE PLATE NUMBER YEAR MAKE13. Judgment debtor(s) identifying information:A DEBTOR FULL NAMEB CURRENT ADDRESSC CA DRIVER LICENSE NUMBERD BIRTHDATE (Month, Day, Year)E DEBTOR FORMER NAME(S) OR AKAF ANY ADDITIONAL ADDRESSInclude any additional judgment debtor(s) information on a separate sheet of paper.14. Name, address and telephone number of judgment creditor or attorney: ( )I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correctSIGNED XDATE Court Report of Judgments (Reference CVC 24716373)The clerk of a court, or the judge of a court which has no clerk, shall issue upon the request of a judgment creditor, a certiied copy of the judgment or a certified copy of the docket entries in an action resulting in a judgment for damages, and a certificate of facts relative to such judgment on a form provided by the Department, the rendering and nonpayment of which judgment requires the Department to suspend the driver license of the judgment debtor. The document shall be forwarded immediately upon the expiration of thirty days after the judgment has become final and when the judgment has not been stayed or satisfied within the amounts specified in this chapter as shown by the records of the court. STATE OF CALIFORNIADEPARTMENT OF MOTOR VEHICLES256A Public Service AgencyDL 30 (REV. 12/2016) WWW American LegalNet, Inc. www.FormsWorkFlow.com DL 30 (REV. 12/2016) WWW CERTIFICATE OF FACTS RE UNSATISFIED JUDGMENT (DL 30) INSTRUCTION SHEET Use this form ONLY for a judgment over $1,000 ($750 if prior to January 1, 2017) issued by a California Court and based on a tort claim as a result of a motor vehicle accident occurring in California. In accordance with California Vehicle Code (CVC) 24716482, the department will not suspend an individual upon COMPLETE THE FORM AS FOLLOWS: The top portion down to #4 must be completed by a California Court. Submit one DL 30 per defendant. (Must agree with judgment exactly) Item 3a, b, or c must show an amount. a) If the court did not order on line 2 c) If the court ordered STATE OF CALIFORNIA Items 9 and 10 must agree exactly with Item 3. suspension action or when unacceptable or incomplete judgment documents are submitted; however, a new fee is not required a nonrefundable $20 judgment processing fee to the address listed below American LegalNet, Inc. www.FormsWorkFlow.com