Appendix C - Statement Of Bail And Payment Received - Arkansas Professional Bail Bondsman Licensing Board

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_____________________________________________________________
Date
Subscribed and sworn to or affirmed before me this ___________________day of ____________________________, 20______________.
____________________________________________
---------------------------------------------------------------------------------------------------------
My Commission Expires
Notary Public
APPENDIX C
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Statement of Bail and Payment Received
NAME OF COMPANY, ADDRESS, CITY, STATE, ZIP CODE
(AREA CODE) PHONE NUMBER
XX___001
Date: ___________________ Agent: _______________________________________________ Bond # _______________________
Arrestee: _____________________________________________________________________ DOB: ________________________
Last
First
Middle
Date & Time of Arrest: ____________________________ A.M./P.M.
Date & Time of
Release__________________A.M./P.M.
Court: ________________________________________________ Appearance Date & Time: ______________________
A.M./P.M.
Charges _____________________________________________________________
Amount of Bail _______________________
____________________________________________________________________
Premium ____________________________
Collateral:
NO □
YES □
Collateral Receipt #________________
Filing Fee ___________________________
Arrestee: ____________________________________________________________
State Fee ____________________________
Agent: ______________________________________________________________
TOTAL ____________________________
Co-Signer ___________________________________________________________
Amount Paid _________________________
Co-Signer ___________________________________________________________
Balance Due _________________________
27

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