IN THE COURT OF COMMON PLEAS OF ADAMS COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
No. ___ -S-___
Appellant
V.
COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF TRANSPORTATION, BUREAU OF DRIVER LICENSING
Appellee
The undersigned hereby certifies that on _____, 20___, I caused to be mailed by United States certified mail, return receipt requested, a copy of the Appeal From Suspension/Revocation of Operating Privileges filed in the above matter, to the Pennsylvania Department of Transportation, Office of Chief Counsel, Third Floor, Riverfront Office Center, Harrisburg, Pennsylvania 17104-2516. The return receipt signed by a representative of the Pennsylvania Department of Transportation is attached hereto.
Date
Appellant