You, the undersigned Defendant (“Defendant” or “you”), hereby represent and warrant that the following declarations made and answers given
are true, complete and correct and are made for the purpose of inducing American Surety Company (“Surety”) to issue, or cause to be issued, bail
bond(s) or undertaking(s) for you (singularly or collectively the “Bond”), using power of attorney number(s) (if known)
Attorney Number(s)
Total amount
in the
Court of
1. DEFENDANT’S NAME AND ADDRESS
Name
Nickname/Alias
Home Phone #
Cell Phone #
Work Phone #
Current Home Address
How Long?
Landlord
Former Home Address
How Long?
Landlord
How long resided in current city?
How long in current state?
2. PERSONAL DESCRIPTION
Date of Birth
Where Born
Race
Social Security #
Driver’s License #
Issuing State
Height
Weight
Eye Color
Scars, Marks, Tattoos
Complexion
How Long in U.S.?
Nationality
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua & Deps
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Rep
Chad
Chile
China
Colombia
Comoros
Congo
Congo {Democratic Rep}
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland {Republic}
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea North
Korea South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar, {Burma}
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russian Federation
Rwanda
St Kitts & Nevis
St Lucia
Saint Vincent & the Grenadines
Samoa
San Marino
Sao Tome & Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Alien #
Any Medical Conditions/Disabilities
Union?
Local #
Military Service: Branch
Active?
Discharge Date
3. EMPLOYMENT
All Occupations for the past 5 years:
Current Employer
Name
How Long?
Position
Supervisor’s Name
Phone #
Most Recent Former Employer
Name
How Long?
Position
Supervisor’s Name
Phone #
Next Most Recent Former Employer
Name
How Long?
Position
Supervisor’s Name
Phone #
4. MARITAL STATUS/CHILDREN
Spouse/girl/boyfriend’s Name
How Long Married/together?
Address (if different)
Email
Home Phone # (if different)
Cell Phone #
Social Security #
Occupation
Employer
How Long?
Supervisor’s Name
Work Phone #
Child’s Name
Date of Birth
School/Employer
Other Parent’s Name
Child’s Name
Date of Birth
School/Employer
Other Parent’s Name
5. VEHICLE
Describe Auto:
Year
Make
Model
Color
Plate #
State
Alaska
Alabama
Arkansas
American Samoa
Arizona
California
Colorado
Connecticut
District
of Columbia
Delaware
Florida
Georgia
Guam
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
Montana
North Carolina
North Dakota
Nebraska
New Hampshire
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Virginia
Virgin Islands
Vermont
Washington
Wisconsin
West Virginia
Wyoming
Where Financed?
Amount Owed? ($)
Insurance Agent’s Name:
Insurance Agent’s Phone #
6. ARREST INFORMATION
Date of Arrest
Booking Name (if different)
Arresting Agency
Jail Location
Booking #
Charges
Previous Arrests:
Charges
Date
Where
Charges
Date
Where
Pending Charges in Other Counties
Parole/probation officer name
Parole/probation officer phone #
Bonded before by
When?
7. ATTORNEY
Name and Firm
Phone #
Email
Amount of retainer paid $
8. RELATIVES AND FRIENDS
Father’s Name
Address
Home Phone #
Cell Phone #
Work Phone #
Employer
Email
Mother’s Name
Address
Home Phone #
Cell Phone #
Work Phone #
Employer
Email
Other Relative/Friend’s Name
Relation
Address
Home Phone #
Cell Phone #
Work Phone #
Employer
Other Relative/Friend’s Name
Relation
Address
Home Phone #
Cell Phone #
Work Phone #
Employer
Other Relative/Friend’s Name
Relation
Address
Home Phone #
Cell Phone #
Work Phone #
Employer
9. NOTES
Write notes here
TERMS AND CONDITIONS
1. In consideration of Surety, through its producers, representatives or designees, issuing or causing to be issued the Bond, you agree to the following terms and conditions:
The premium is fully earned upon your release from custody. The premium is not refundable except as stated below.
Other Conditions
4. You shall indemnify the Surety and keep the Surety indemnified and hold it harmless from and against any and all losses, demands, liabilities, fees and expenses relating to, or arising out of, Surety’s issuance or procurement of the Bond including, but not limited to, the following: (a) the principal amount of any forfeiture of, or judgment on, the Bond, plus any related court costs, interest and legal fees incurred, (b) a fugitive recovery fee if there is a forfeiture of the Bond (which fee is typically ten percent of the amount of the Bond for an in-state recovery), plus any out of pocket expenses, (c) any and all extradition costs that may be incurred to apprehend and return you, and (d) if a collection action is required, reasonable and actual attorneys’ fees plus any other costs, expenses and/or assessments that may be incurred as a result of any forfeiture of the Bond subject to applicable law (if any) as stated in an attached addendum. The voucher, check or other evidence of any payment made by Surety or its producer, by reason of such suretyship, shall be conclusive evidence of such payment in any lawsuit against you both as to the propriety of such
payment and as to the extent of your liability to Surety for such payment. Further, you will, upon demand, place with Surety the requisite funds to meet any such claim, demand, liability, attorneys’ fees, expense or judgment, whether that demand is made before or after Surety has paid or advanced such funds.
ALABAMA RESIDENTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof
ARKANSAS RESIDENTS
Any person who knowingly presents a false or fraudulent claim for payment for a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
FLORIDA RESIDENTS
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
LOUISIANA, RHODE ISLAND & WEST VIRGINIA RESIDENTS
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MAINE, TENNESSEE, VIRGINIA & WASHINGTON RESIDENTS
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of - defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MARYLAND RESIDENTS
Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NEW JERSEY RESIDENTS
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
NEW MEXICO RESIDENTS
ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.
NEW YORK RESIDENTS
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
OHIO RESIDENTS
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OKLAHOMA RESIDENTS
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
PENNSYLVANIA RESIDENTS
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person criminal and civil penalties
Signed, sealed and delivered this
Date
Submit Identification Document “Government ID/ Driver’s License/ Passport
SURETY:
American Surety Company
BAIL PRODUCER:
[stamp must include name, address, phone no. and license no.]
Send
