ILLINOIS SECRETARY OF STATE
DRIVER SERVICES DEPARTMENT
REPORT ON CIVIL JUDGMENT INVOLVING A MOTOR VEHICLE ACCIDENT
(MUST BE FILE-STAMPED BY COURT)
PLAINTIFF VS.
DEFENDANT
DEFENDANT ADDRESS (STREET)
CITY
STATE
ZIP
DATE OF BIRTH
DATE OF ACCIDENT
DATE OF JUDGMENT
DRIVER’S LICENSE NUMBER
Check the appropriate box:
INSTALLMENT AGREEMENT ORDERED: I hereby certify that on , , the
court entered an order authorizing payment by installment agreement.
DEFAULT OF INSTALLMENT AGREEMENT: I hereby certify that on , ,
the court entered an order that the defendant is in default of, and vacated, the installment agreement.
JUDGMENT RELEASED: I hereby certify that on , , having received full
satisfaction of all sums of monies due from the judgment debtor, the judgment was released by the
judgment creditor.
JUDGMENT VACATED: I hereby certify that on , , the court entered an
order vacating the judgment that was rendered on , .
NAME OF COURT
CITY
COUNTY
STATE
NAME OF ATTORNEY
ADDRESS (STREET)
PHONE
CITY
STATE
ZIP
SIGNATURE OF ATTORNEY SUBMITTING FORM
ARDC #
Printed by authority of the State of Illinois. February 2018 3M DSD A 309
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