PRODUCERS - See instructions on bottom stub of this form for proper client copy separation
BAIL BOND AGREEMENT ("Agreement")
PRODUCER NAME, ADDRESS, PHONE, EMAIL AND PRODUCER LICENSE NUMBER MUST BE PREPRINTED OR STAMPED HERE:
Ed Williams
1815 N. Cocoa Blvd, Cocoa, FL 32922
321-639-5151
Lic #A285170
info.aamerican@gmail.com
THIS IS A DOUBLE SIDED DOCUMENT
READ ALL SIDES CAREFULLY
In consideration of Allegheny Casualty Company ("Surety"), through Surety's duly appointed independent bail producer ("Bail Producer"), (Surety and Bail Producer are sometimes together referred to as "Surety"), issuing, or causing to be issued, a criminal appearance bail bond described as:
Date
*
Defendant Name
*
Total Bond Amount $
Indemnitor Name(s)
*
Total Premium $
Power Number(s)
("Bond")
I/we represent and warrant that I/we have read, approve and agree to all of the terms and conditions found on following pages (front and back).
Signed, sealed and delivered this
Defendant Signature
Indemnitor Signature
Print Name
*
Print Name
*
Indemnitor Signature
Indemnitor Signature
Print Name
*
Print Name
*
Indemnitor Signature
Indemnitor Signature
Print Name
*
Print Name
*
Check box and complete the following if translation is required
Translation Certification. The undersigned translator makes this affidavit and hereby certifies, under penalty of perjury, that he/she read verbatim and translated this entire document, including the reverse side, and all related bond application documents including disclosures, promissory notes, security instruments and trust deeds, to the Indemnitor signing below in his/her primary language.
Translator Print Name
Translator Signature
Translator Full Address
Date
-
Month
-
Day
Year
Date
Confirmo por mi colocación de mis iniciales que las dos caras de este acuerdo han sido traducidos completamente a mi satisfacción. (I confirm by my affixing my initials that this contract has been translated to my satisfaction.)
INDEMNITOR Initials
READ ALL TERMS AND CONDITIONS ON THE FRONT AND BACK OF EACH PAGE
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A AMERICAN BAIL BONDS
P.O. BOX 61918
PALM BAY, FL. 32906
(321) 639-5151
(321) 984-7100
DATE:
*
-
Month
-
Day
Year
Date
Amount of Bond:
*
Premium
*
Bond #:
Company
I understand in signing this bond for obtaining the release of
*
I am responsible for him/her appearing in Court each time he/she is so ordered; also I understand I am responsible for payment of any court costs for non-appearance if he/she fails to follow any and all instructions or orders of the Court or forfeits this bond, and it becomes necessary to apprehend and surrender him/her to the Court. I understand I am responsible for any and all expenses incurred as a result of such forfeiture and further, if such a forfeiture occurs and defendant is not surrendered to the Court within time prescribed by law, I understand I am required to pay the
FULL AMOUNT
of the bond posted, including unpaid bail premium, if applicable in this state. Should state laws supersede this or any part of the agreement; all other terms are still in full force and effect.
COLLATERAL
cannot be returned until such time as the Company receives written notice from the clerk of the Court
I am not a paid signer. I have no connection with a Bail Bond Consultant.
I have read the above contract and understand it, and agree to fulfill ALL the provisions therein.
SIGNED
Print Name
*
First Name
Last Name
AGENT
1815 N. Cocoa Blvd., Cocoa, FL 32922
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PRODUCER NAME, ADDRESS, PHONE AND PRODUCER LICENSE NUMBER MUST BE PREPRINTED OR STAMPED HERE:
Ed Williams
1815 N. Cocoa Blvd., Cocoa, FL 32922
321-639-5151
Lic #A285170
info.aamerican@gmail.com
BAIL BOND INFORMATION SHEET
Defendant:
*
Power Number(s):
As principal (defendant) and/or indemnitor (guarantor) on a bail bond, you must be given a copy of any collateral documents that you sign relating to the above bond(s).
When all agreements have been fulfilled, bond is discharged in writing by the court, and without loss expense on the bond(s), your collateral will be returned to you.
BE AWARE: YOUR COLLATERAL IS AT RISK if the principal fails to appear in court or if the principal commits any breach (violation) of agreement.
ANY OF THE FOLLOWING HAPPENINGS IS A BREACH OF AGREEMENT:
If principal fails to appear in court;
If principal shall depart the jurisdiction of the court without the written consent of the court and the Surety, or its agent;
If principal shall move from one address to another without notifying the Surety, or its Agent, in writing, prior to said move;
If principal shall commit any act which shall constitute reasonable evidence of principal's intention to cause a forfeiture of the bond(s);
If principal is arrested and incarcerated for any offence other than a minor traffic violation;
If principal shall make any material false statement in the application;
If principal shall violate any special restriction or condition of the bond(s) imposed by the Court.
For general information regarding your collateral, contact the agency as shown on the top of this sheet.
For further inquiry / complaint, contact
Department of Financial Services
Bail Bond Section
200 East Gaines Street
Tallahassee, FL 32399-0320
Phone: (850) 413-5660
PRINCIPAL/INDEMNITOR ACKNOWLEDGMENT
I (We) have received a copy of this information sheet.
I (We) have received a copy of all collateral documents that I (We) signed regarding the above bond(s).
SIGNATURE:
SIGNATURE:
PRINT NAME:
*
PRINT NAME:
*
***** READ CAREFULLY *****
Signed original to agent's bond file
Copy to defendant and each indemnitor
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PREMIUM RECEIPT and STATEMENT OF CHARGES
Receipt No.
PRODUCER NAME, ADDRESS, PHONE, EMAIL AND PRODUCER LICENSE NUMBER MUST BE PREPRINTED OR STAMPED HERE:
Ed Williams, 1815 N. Cocoa Blvd, Cocoa, FL, 32922
Lic #A285170
info.aamerican@gmail.com
Date Received
-
Month
-
Day
Year
Date
Payment Method
Cash
Credit Card
Check
Money Order
Amount Received ($)
Payer Name
*
Payer Phone Number
*
Format: (000) 000-0000.
Defendant
*
Bond Amount ($)
*
Power Number(s)
Case Number(s)
Court
Appearance Date
-
Month
-
Day
Year
Date
Appearance Time
Hour Minutes
AM
PM
AM/PM Option
Collateral Received
Yes
No
Collateral Receipt Number(s)
Rows
Itemized Expense(s) (if and as permitted by applicable law)
Expense Amount
Expense(s)
Expense(s)
Expense(s)
Expense(s)
Bail Bond Premium
Total Expense(s)
Prior Payment(s)
Amount Received
Remaining Balance
Payer Signature
Producer/Representative Signature
Print Name
*
Producer/Representative Print Name
Form# ACC.0304-1 (10/21)
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COLLATERAL RECEIPT
Receipt No.: ACFL-
ALLEGHENY CASUALTY COMPANY
P.O. BOX 9810, CALABASAS, CA 91372-9810
TELEPHONE (800) 935-2245
PRODUCER NAME, ADDRESS, PHONE AND PRODUCER LICENSE NUMBER MUST BE PREPRINTED OR STAMPED HERE:Ed Williams, 1815 N. Cocoa Blvd., Cocoa, FL 32922Lic #A285170info.aamerican@gmail.com
Deposit of collateral: Depositor hereby acknowledges receipt of a copy of this document and agrees to the terms on the reverse side. The collateral identified below is deposited as security for the bail bond(s), premium owed, if any, and all lawful expenses incurred due to underwriting the referenced bail bond(s).
Return of collateral: Depositor hereby surrenders the original and acknowledges the return and receipt of collateral listed herein and that the collateral has been returned in good and sufficient condition. Depositor hereby relieves the surety and its bail producer from any further liability or responsibility in relation to the collateral.
Returning collateral from receipt number(s)
Depositor Name
*
First Name
Middle Initial
Last Name
Date Received
*
-
Month
-
Day
Year
Date
Depositor Address
*
Depositor Phone #
*
Format: (000) 000-0000.
Defendant
*
First Name
Middle Initial
Last Name
Case #
Power No.(s)
Bond Amt.
*
Rows
Collateral Received - describe below, specify condition
Amount or Estimated Value
Held By
Held By
Held By
1
2
3
Collateral Funds - in form of
Cash
Check
Money Order
Credit Card
$
Bail Producer
Surety
MGA
Depositor:
Bail Producer:
Print Name
*
Print Name
Form# ACC.FL.0304-2 (03/14)
ONLY FOR USE IN FLORIDA
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