Collateral Receipt

Agent Name

Phone

License #

Address

Street Address City State / Province / Region ZIP / Postal Code

Date

DEPOSITOR’S NAME

First Last

Address

Street Address City State / Province / Region ZIP / Postal Code

PHONE NUMBERS:

HOME

WORK

MOBILE

The person named on line two (2) above (“Depositor” or “you”) has deposited the following collateral:

In the amount of

Dollars

Paid by way of

Cash
Check
Other

Itemize and describe source of other

If collateral is other than money, check the following:

Vehicle
Mortgage Agreement
Other

Describe and specify condition

The above collateral is placed as security for the bail bond(s), premium owed, if any, and all lawful costs incurred due to underwriting the bail bond(s) for the following:

DEFENDANT

CASE NO

BOND AMOUNT: $

POWER NUMBER

COURT

CHARGES

Name of Bail Agent

Signature of Bail Agent

COLLATERAL HELD BY (check one):

Bail Producer
Surety
Managing General Agent

Except as otherwise provided by applicable law (if any) as stated in an addendum attached to the Indemnity Agreement (“Agreement”), you are depositing the collateral as security for the payment of any and all monies and sums due to O’Shaughnahill Surety & Insurance, Inc. (the “Surety”) or its agents, including all liability, claims, demands, debts (including promissory notes), damages, judgments, losses, interest, premiums, expenses, services charges, expenditures, attorneys’ fees and costs suffered, sustained, made or incurred by the Surety or its agents on account of, arising out of or relating to the above bail bond and transactions contemplated thereby, your failure to comply with the terms and conditions of the Agreement and any and all debt or other obligations arising out of or evidenced by any agreement executed by you, Defendant or any other indemnitor(s) for the benefit of Surety or its agent, all of the terms of which are made a part of this receipt by this reference (“Liabilities”). NOTE: Unless a properly drawn, executed and notarized legal assignment document is accepted and acknowledged by the Surety or its designee, the collateral listed above will be returned only to you. Except as otherwise provided by applicable law (if any) as stated in an addendum attached to the Indemnitor Application and Agreement, the collateral shall be returned to you, your heir, legal representative or successor in interest (less any Liabilities) within 21 days after all of the following are satisfied: (i) the Surety receives competent written legal evidence satisfactory to the Surety (such as, for example, written notice from the court) of the Surety’s discharge or release from all liability under the above bail bond; (ii) there are no outstanding Liabilities; (iii) there are no other outstanding bonds or obligations executed by, for or on behalf of you or Defendant in connection with which the Surety may deem it advisable, in its sole discretion, to retain such collateral for its protection; and (iv) upon the Surety’s request, you shall have executed and delivered to the Surety a general release upon the Surety’s return of the collateral to you.

In Florida, if you are using a credit card to provide collateral, you are required to pay an additional credit card fee in the following amount:

Amount $

Florida Administrative Code Rule 69B-221.120: For any complaints or inquiries, the consumer may contact the Department of Financial Services, Division of Consumer Services, Bail Bond Section, 200 East Gaines Street, Tallahassee, FL 32399-0322, 1-877-693-5236 (in-state)

You hereby acknowledge receipt of a copy of this document and of all documents referenced above, and the above conditions are understood and agreed to:

DEPOSITOR’S SIGNATURE

RECEIPT FOR RETURN OF COLLATERAL

You hereby surrender the original of this collateral receipt and acknowledge the return and receipt of collateral listed above. The collateral has been returned in good and sufficient condition and you hereby relieve the Surety and its agent from any further liability or responsibility in relation to the collateral. You have received the items listed below:

TOTAL AMOUNT RETURNED $

Other collateral returned:

Date

Received by:

Returned by

BAIL BOND PREMIUM RECEIPT

Received from

Receipt Date

The Sum of

Amount $

CASH
CHECK
CREDIT CARD
MONEY ORDER

Defendant

Bond Amount $

Power of Attorney No.

Court

Collateral Receipt No.

Charged with

BAIL BOND PREMIUM*

MISC: CHARGES

TOTAL CHARGES

RECEIVED ON ACCOUNT

BALANCE

Print Name

Received by