Your Name

Street Address

Address (cont.)

City

State

Zip Code

Home Phone

Work Phone

Email Address

How do you want to be contacted?

Choose One Home Phone Work Phone Email Address

Judgment Amount

Case Number

Judgment Debtor

Choose One Person Two People Company/DBA Corporation

Debtor’s Name

Has the debtor filed bankruptcy?

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Judgment Court

Judgment City

Judgment County

Judgment State

Judgment Date

Comments

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