IN THE COURT OF COMMON PLEAS OF ________________ COUNTY, PENNSYLVANIA CIVIL DIVISION : : : : : : : : : File No. ________________________ CERTIFICATION The undersigned hereby certifies that the attached Praecipe for Execution / Attachment does not arise out of a retail installment sale, contract, or account based on a confession of judgment, but if it does, it is based on the appropriate original proceeding filed pursuant to Act 7 of 1966 as amended. Date: __________________ Signature: ____________________________ Print Name: ____________________________ Attorney for Plaintiff Address: ______________________________ ______________________________ Telephone: ____________________________ Supreme Court ID No.: __________________ Q-1F-1 (Rev. 4/00) American LegalNet, Inc. www.FormsWorkflow.com