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This is a Maryland form that can be used for Motor Vehicle Administration within Statewide.
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Motor Vehicle Administration 6601 Vehicle Administration Motor Ritchie Highway, N.E. Glen Burnie, Maryland 21062 6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062 ICD-022 (01-04) ICD-022 (03-13) (Sec., 17-202, Maryland Transportation Article, Vehicle Laws) (Sec., 17-202, Maryland Transportation Article, Vehicle Laws) Certificate of Facts Relative to Judgment Certificate of Facts Relative to Judgment Note: No action will be taken unless: (1) this judgment is a result of Motor Vehicle accident damages, (2) this form is completed in its entirety (including full name of the defendant(s), date of birth and/or driver's license number), (3) a certified copy of the judgment is attached, and (4) the judgment appeal period has expired. This is to certify that on in the Against: Full Name: Address: Driver's License Number: Reciprocity States to Notify: In Favor of: Name of Plaintiff(s): Address of Plaintiff(s): Date of motor vehicle accident: Signature: Name of Plaintiff's Attorney: Address of Plaintiff's Attorney: Telephone Number of Plaintiff's Attorney: Attorney Case #: Mail to: Insurance Compliance Division Motor Vehicle Administration 6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062 with Certified Copy of Judgment Attached Court case number: Date: First Middle Last Date judgment was entered, from which no appeal has been taken, Court of Date of Birth: For more information, please call: 410-768-7000 (to speak with a customer service representative). TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov American LegalNet, Inc. For more information, please call: 1-800-638-8347 (touch tone calls only), 1-800-950-1MVA (1682) (to speak with a customer service www.FormsWorkFlow.com representative),