Penndot Certification Of Motor Vehicle Judgment - Erie County
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1DL-201 (4-08)
CERTIFICATION OF
COURT INFORMATION
Bureau of Driver Licensing
COURT
MOTOR VEHICLE JUDGMENT
P.O. Box 60037
Harrisburg, PA 17106-0037
COUNTY
NUMBER
TO THE SECRETARY OF TRANSPORTATION
YEAR
This is to certify that on _________________________________________ a judgment
for $____________________ plus $_________________ was entered against the following:
(AMOUNT)
(COST)
(Please use a separate form for each)
JUDGMENT DEBTOR
(Please Print or Type)
NAME
DATE OF BIRTH
SEX
FIRST
MIDDLE
LAST
MONTH
DAY
YEAR
ADDRESS: P.O. Box number may be used in addition to the actual address, but cannot be used as the only address.
CITY
SOCIAL SECURITY NUMBER
STATE
ZIP CODE
-
-
DRIVER NUMBER
STATE
DATE OF ACCIDENT
CLAIM NUMBER
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
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