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SURETY BAIL BOND PREMIUM RECEIPT
Receipt Number: (Printed auto increment #)
Receipt Date:
1. RECEIVED FROM:
2. The Sum of:
($ )
3. Cash Check Money Order ---- PREMIUM ON BOND(S) FOR:
4. Defendant:
Bond Amount: $
5. P/A #
Court:
6. Charged with:
7. Collateral Receipt No. issued. (ENTER RECEIPT # OR “NONE”)
NOTICE: SEE REVERSE SIDE
Amt. Due $
Received By:
Amt. Pd. $
(Signature)
(Print)
In Behalf of Agent for:
Bal. Due $ ________________________ Financial Casualty & Surety, Inc. (fcs)
PO Box 4479, Houston, TX 77210-4479
877-737-2245
FCS Prem Rcpt FL (2/2007) PAYOR’S COPY
Reverse Side
ANY OF THE FOLLOWING HAPPENINGS SHALL CONSTITUTE A BREACH OF YOUR AGREEMENT
a. If principal shall depart the jurisdiction of the court without the written consent of the court and the surety, or
its agent.
b. If principal shall move from one address to another without notifying the surety, or its agent, in writing prior
to said move.
c. If principal shall commit any act which shall constitute reasonable evidence of principal’s intention to cause
a forfeiture of said bond.
d. If principal is arrested and incarcerated for any offense other than a minor traffic violation.
e. If principal shall make any material false statements in the application.
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
THE BOND(S) SET FORTH IN THIS RECEIPT SHALL BE CONSIDERED TO BE IN FULL FORCE AND
EFFECT UNTIL DISCHARGED IN WRITING BY THE COURT.
A
g
ent Name, Address & Phone #