STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DISTRICT COURT PROOF FINANCIAL RESPONSIBILITY TO: THE REGISTRAR OF MOTOR VEHICLE, PROVIDENCE, RHODE ISLAND In accordance with the provisions of G.L. 1956 § 31-32-8, entitled PROOF OF FINANCIAL RESPONSIBILITY, I, the undersigned Clerk of the above named Court do hereby certify that in the case of: Plaintiff Civil Action File Number Defendant The following entry made on ____________________________. Judgment may be entered for the Plaintiff in the sum of $___________________ plus interest and costs. That said judgment has become final and has been in effect for more than sixty (60) days and according to the records of this court has not been satisfied or discharged, nor has the Defendant applied to this court for the privilege of paying such judgment in installments. According to the pleadings filed in the case, the judgment is for damages to property resulting from the ownership, maintenance, use, or operation of a motor vehicle by the Defendant on ______________________________. In testimony whereof, I have hereunto set my hand and affixed the seal of said court at __________________, County of __________________ and State of Rhode Island this_______________ day of _______________________, A.D., 20______. ENTERED: BY ORDER: ____________________________________ Judicial Officer ___________________________________ Clerk DC-58 (revised November 2014) American LegalNet, Inc. www.FormsWorkFlow.com