United States Fire Insurance Company
11490 Westheimer R., Suite 300 77077
P.O. Box 2807 · Houston, TX 77252-2807
(713) 954-8100 · (713) 954-8389

BAIL BOND APPLICATION AND AGREEMENT

(Please answer each question in full. Please print answers)

THIS IS A 4 PAGE DOCUMENT

Youuu, 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 United States Fire Insurance 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)
,
in the total amount of
Dollars ($)
in the
Court of
1. DEFENDANT'S NAME AND ADDRESS
Name
Nickname/Alias
FIRST
MIDDLE
LAST
.
Home phone
cell phone
work phone
email:
current home address
how long
rent own landlord
former home address
how long
rent own landlord
How Long Resided In Current City
How Long In Current State
2. PERSONAL DESCRIPTION
date of birth
where born
sex male female race
social security #
driver's license #
Issuing State
height
weight
eye color
hair color
Scars, Marks, Tattoos
complexion
how long in U.S
U.S citizen yes no nationality
alien#
Any Medical Conditions/Disabilities
union
local#
military service branch
active yes no discharge date
3. ARREST INFORMATION
Date of Arrest
Booking Name (if different)
Arresting Agency
jail location
booking #
charges
previous arrests:
CHARGES
DATE
WHERE
Pending Charges in Other Counties
Are You On Probation yes No Parole/Probation Officer Name And Phone #
Are You Now Under Any Bond yes No Have You Ever Failed To Appear In Court yes No
Bonded Before By
When
4. EMPLOYMENT
All Occupations For The Past 5 Years
current employe name
how long
position
Supervisor's Name
work phone
Most Recent Former Employer Name
how long
position
Supervisor's Name
work phone
Next Most Recent Former Employer Name
how long
position
Supervisor's Name
work phone
5. MARITAL STATUS/CHILDREN
Married Divorced Seperated Widowed Single Cohab
Spouse/Girl/Boyfriend's Name
How Long Married/Together
First
Middle
Last
Address (if different)
Email
Home Phone
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
6. VEHICLE
describe auto: year
make
model
color
plate #
state
where financed
amount owed
insurance agent's name
insurance agent's phone
7. ATTORNEY
Name and firm
phone#
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
cell phone
work phone
employer
email
Other Relative/Friend's Name
relation
address
cell phone
work phone
employer
email
9. OTHER CONDITIONS - Refer To Item 3j On Reverse Side

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

NEW YORK RESIDENTS must also sign the last page of this Agreement.

I agree to the terms set forth on all 4 Pages of this agreement.
Signed, Sealed And Delivered at
Date
Month
Year

*** By typing my name below, I am electronically signing this bail bond application & agreement.
signature of Witness
signature of Defendant
print
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Bailbonds Agreement Terms