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Bond / Court Information    Defendant Full Name:   Date of bond: -- 01 02 03 04 05 06 07 08 09 10 11 12 / -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / ---- 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010   Bond Amount: $   Court County:   Power No.(s): Description of Charges: Card Holder Information Only   Name on Credit Card:   Billing Address:   City:   State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Zip Code:   D.O.B.: -- 01 02 03 04 05 06 07 08 09 10 11 12 / -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / ---- 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010   Email:   Phone:   Fax :   Drivers Licence:   Visa | Master Card   Credit Card No.:   Expiration Date: -- / ----   3 Digit Verification Code (CSC): Charge Details   Premium: $   3.8% Card Fee: $  Total Charge $ Check Box to authorize charges:

Notice of Credit Card Fee Imposed For Payment of Collateral:Effective July 1, 2002 pursuant to 648.571 (3) (b) (1) (2): A bail bond agent may charge the fee imposed in connection with the use of a credit card for payment of collateral if the fee is clearly shown on the required collateral receipt and is acknowledged by the person tendering the credit card. The prevailing schedule of credit card fees must be conspicuously posted in the lobby of the bail bond agency and a copy of the fee schedule must be provided to the person tendering the credit card. The rate of 3.5% is deducted from the collateral posted on each transaction executed in the office and a rate of 3.8% on each transaction executed over the telephone.

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