COURT INFORMATION
COURT
COUNTY
NUMBER
YEAR
CERTIFICATION OF
MOTOR VEHICLE JUDGMENT
DL-201 (4-08)
Bureau of Driver Licensing
P.O. Box 60037
Harrisburg, PA 17106-0037
TO THE SECRETARY OF TRANSPORTATION
This is to certify that on _________________________________________ a judgment
for $____________________ plus $_________________ was entered against the following:
(AMOUNT)
(COST)
DRIVER NUMBER
MONTH DAY YEAR
SEX
DATE OF BIRTHNAME
ADDRESS: P.O. Box number may be used in addition to the actual address, but cannot be used as the only address.
FIRST MIDDLE LAST
-
-
SOCIAL SECURITY NUMBER
ZIP CODE
STATE
CITY
CLAIM NUMBER
DATE OF ACCIDENT
STATE
❏ Check this block if defendant is a resident of another state
REPRESENTATIVE FOR THE JUDGMENT
JUDGMENT CREDITOR CREDITOR (If applicable)
__________________________________________________ __________________________________________________
(NAME) (NAME)
__________________________________________________ __________________________________________________
(STREET ADDRESS) (STREET ADDRESS)
__________________________________________________ __________________________________________________
(CITY & STATE) (ZIP) (CITY & STATE) (ZIP)
__________________________________________________ __________________________________________________
(TELEPHONE NUMBER) (TELEPHONE NUMBER)
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 ______________________________ 19_____ _________________________________________________________
(SIGNATURE OF CLERK OR PROTHONOTARY
OF THE COUNTY COURT)
SEAL _________________________________________________________
(TYPE OR PRINT NAME)
RETURN COMPLETED Bureau of Driver Licensing, P.O. Box 60037,
FORM TO: Harrisburg, Pennsylvania 17106-0037
(Please use a separate form for each)
JUDGMENT DEBTOR
(Please Print or Type)
