PENNSYLVANIA DEPT. OF TRANS. DATE___________________________ BUREAU OF DRIVER LICENSING CERTIFICATION OF COUNTY COUNTY _______________NO.______ P.O. BOX 2253 MOTOR VEHICLE HARRISBURG, PA. 17105 JUDGMENT NO._________TERM_________2_____ (PLEASE TYPE) TO THE SECRETARY OF TRANSPORTATION This is to certify that on ________________________ a judgment for $______________ plus $______________ was entered against the following: (Amount) (Cost) 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)