Form Dl 201 – Fill Out and Use This PDF

for $____________________ plus $_________________ was entered against the following:

(AMOUNT)

(COST)

(Please use a separate form for each)

JUDGMENT DEBTOR

(Please Print or Type)

NAME

SEX

DATE OF BIRTH

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

STATE

ZIP CODE

SOCIAL SECURITY NUMBER

-

-

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)

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