Financial Statement & Indemnity Agreement Form

PALMETTO SURETY

CORPORATION

75 PORT CITY LANDING, SUITE 130•MOUNT PLEASANT, SC 29454
FINANCIAL STATEMENT AND

INDEMNITY AGREEMENT

AGENT

POWER NO.

CASE NO.

EXECUTION DATE

NAME OF INDEMNITOR

PHONE NUMBER

DATE OF BIRTH

FIRST MIDDLE LAST

RESIDENCE ADDRESS

CITY

STATE

ZIP

SOCIAL SECURITY #

EMAIL

PHONE NUMBER

EMPLOYED BY

ADDRESS

PARENTS

ADDRESS

PERSONAL REFERENCES WORK OR HOMES ADDRESSES PHONE

ASSETS LIABILITIES

Cash in

Bank

Money Borrowed on Notes

$

Stocks, bonds, mortgages (market value):

$

.

$

.

$

.

Real estate, the title to which in my name alone *

$

Mortgages on real estate scheduled opposite

$

A.

$

A.

$

B.

$

B.

$

Account receivable

$

Accounts Payable

$

Other assets (in detail)

$

Other Liabilities (in detail)

$

Total Assets

Total Liabilities

The make of the above statement hereby authorizes the Surely to confirm the bank balances claimed and all other items comprising said statement.

YOU ARE ASSUMING SPECIFIC OBLIGATIONS - READ CAREFULLY!
INDEMNITY AGREEMENT

THIS AGREEMENT is made by and between the undersigned Defendant, Indemnitors, and Palmetto Surety Corporation through its duly authorized Agent.

WHEREAS, Palmetto Surety Corporation (hereinafter called "Surety"), at the request of the Indemnitors has or is about to become SURETY on an appearance bond for Defendant in the sum of

Dollars

by its certain bond executed on the power of attorney numbers

NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties jointly and severally agree as follows:

1. For good and valuable consideration, the undersigned principal agrees to indemnify and hold harmless the surety company or its agent for all losses not otherwise prohibited by law or by the rules of the Department of Financial Services.

2. That the Indemnitors will have Defendant forthcoming before the Court named on said Bond at the time(s) therein fixed, and at such other times as may be ordered by the Court.

3. That the Indemnitors will at all times indemnify and save the Surety harmless from and against any and all claims, demands, liabilities, costs, charges, counsel fees, expenses, suits, orders, judgments, or adjudications whatsoever which the Surety shall or may for any cause sustain or incur, by reason of Surety having executed said Bond or undertaking, and will, upon demand, place the Surety in funds to meet all such claims, demands, liabilities, costs, charges, counsel fees, expenses, suits, orders, judgments, or adjudications against it, by reason of its Suretyship, and before the Surety shall be required to pay the same.

4. That the agreement of indemnity contained in paragraph 2 above shall continue as long as the SURETY has any liability or has sustained any loss, upon the bond referred to herein, and the undersigned further agrees not to make any transfer, or any attempted transfer of any of the property, real or personal, in which the undersigned has an interest or in which the undersigned may subsequently acquire any interest, and it is further agreed that the SURETY shall have a lien upon all property of the undersigned for any sums due it or for which it has become, or may become, liable by reason of its having executed the bond referred to herein. It is further agreed that the Indemnity Agreement contained in Paragraph 2 above and the provisions of this paragraph shall be binding upon and apply to any subsidiary, affiliate, parent, or related enterprise created or acquired by the undersigned.

5. The voucher, or any other evidence of any payment made by the Surety, by reason of this Suretyship, shall itself, be conclusive evidence of such payment as to the indemnitors, their estate, and those entitled to share in their estate, and their successors and assigns.

6. That the Surety may withdraw: at any time provided by law, from its Suretyship upon the Bond or undertaking herein, without liability to any party.

7. That Indemnitors' liability to Surety is not limited to the Bond referred to herein, but sha'l apply to all other bonds or undertakings issued by Surety at the request of the indemnitors.

8. The Indemnitors' obligations and indemnities as contained herein shall not terminate upon exoneration of the bond or undertaking but shall continue until such time that Surety is relieved of all duties, demands, liabilities, obligations, costs or expenses in any way related thereto.

9. That the waiver by Surety of any breach of any term or conditions herein shall not be deemed a waiver of same of any subsequent breach of the same term or condition, and that failure of any Indemnitor to comply with the terms and conditions herein shall not act as or be construed as a release or waiver as the remaining Indemnitor who shall remain liable and bound by all provisions of this Agreement.

10. This Agreement shall be construed and enforced under the laws of the State of. In the event any of the provisions of this Agreement are inconsistent with the laws of this State, this Agreement, as to these provisions only, shall be null and void, and the remainder shall be enforced with the same effect as though such provisions were omitted.

11. The use of the plural herein shall include the singular. Obligations of the Indemnitors shall be joint and several and the provisions of this Agreement shall be binding upon Indemnitors' heirs, successors, representatives and assigns.

IN WITNESS WHEREOF, the parties have executed this Agreement this, (day of)

WITNESSES

SIGNATURE OF DEFENDANT *

WITNESSES

SIGNATURE OF INDEMNITOR *

WITNESSES

SIGNATURE OF CO-INDEMNITOR *

STATE OF

COUNTY OF

On this

day of

.

before me personally appeared

to me known to be the person

describe in and who executed the forgoing instrument and

therefore acknowledged to me that -- executed the same.

PROMISSORY NOTE

$

City and State

.

ON DEMAND after date, for the value received

Promise to pay to the order of PALMETTO SURETY CORPORATION

or assigns

DOLLARS at

with interest thereon at the rate of

percent, per annum from Call Date until fully paid. Interest is payable semi-annually. The make and endorse of -this note further agree to waive demand, a notice of non-payment and protest; and in case suit shall be brought for the collection hereof, or the same has to be collected upon demand of an attorney, to pay reasonable attorney's fees for making such collection. Deferred interest payments to bear interest from maturity at

.

percent, per annum payable semi-annually. It is further agreed and specifically understood that this note shall become Null and Void in the event the said defendant

.

shall appear in the court at the time or times so directed by the Judge or Judges of competent jurisdiction until the obligations under the appearance bond or bonds posted on behalf of the defendant have been fulfilled and the Surety discharged of all liability thereunder, otherwise to remain in full force and effect.

SIGNATURE OF DEFENDANT *

SIGNATURE OF INDEMNITOR *

SIGNATURE OF CO-INDEMNITOR *

CJ & V BAIL BONDS, LLC

3923 Lake Worth Rd, Ste 216 Palm Springs, FL 33461

(O)#: 561.507.5676

(C)#: 561.512.6538

1. COLLATERAL RECEIVED (Describe in detail)

Contingent Promissory Note

Indemnity Agreement

Contingent Mortgage Agreement

2.

Credit Card Amount

3. RECEIVED FROM

4. Address

AS SECURITY BOND(S) For

5. Defendant

Bond Amount

6. Power #

Court

7. Charged with

8. I acknowledge a Credit Card fee of, (%)

NOTICE - UNLESS A LEGAL ASSIGNMENT DOCUMENT IS FURNISHED TO THE BONDSMAN, COLLATERAL WILL BE RETURNED ONLY TO THE PERSON(S) NAMED IN ITEM 3 ABOVE.

Received By

THIS COLLATERAL WILL BE HELD IN THE CUSTODY OF

THE BONDSMAN

THE COMPANY

GENT AGT

IN TRUST FOR PALMETTO SURETY CORPORATION

75 PORT CITY LANDING, SUITE 130•MOUNT PLEASANT, SC 29454

1-866-372-0827 www.palmettosurety.net

**FOR ANY COMPLAINTS OR INQUIRIES CONTACT YOUR STATE DEPARTMENT OF INSURANCE, FOR THE FLORIDA DEPARTMENT OF INSURANCE CONTACT 200E GAINES ST. TALLAHASSEE, FL 850-413-3140**

IMPORTANT! Palmetto Surety Corporation accepts and authorizes its representatives to accept only specific forms of collateral as security.

THIS ACCEPTABLE COLLATERAL IS LIMITED TO:

1. CASH including cashier's checks, money orders, and certified checks;

2. Properly assigned SAVINGS ACCOUNTS represented by passbooks, or properly assigned CERTIFICATES OF DEPOSIT;

3. Properly assigned STOCKS AND BONDS;

4. REAL ESTATE evidenced by properly executed mortgages, deeds of trust, or confessions of judgment in accordance with applicable state law.

IMPORTANT! This collateral security agreement should not be used except in conjunction with acceptable collateral. Representatives are not authorized to accept and Palmetto Surety Corporation is not responsible for any type or form of collateral other than the collateral enumerated above.

TO DEFENDANT AND INDEMNiTOR(S): YOU ARE ENTITLED TO A SIGNED RECEIPT FOR COLLATERAL YOU HAVE GIVEN TO THE BONDING AGENT TO SECURE AND INDEMNIFY THIS BOND PURSUANT TO THE TERMS OF THIS AGREEMENT. ANY PROPERTY DEED OR MORTGAGE MUST BE TAKEN IN THE NAME OF PALMETTO SURETY CORPORATION. BE SURE ALL YOUR IS ITEMIZED ON YOUR COLLATERAL RECEIPT.

I HAVE (NOT) DEPOSITED COLLATERAL with the Agent for the purpose of this Bail Bond and received Receipt Numbered

AGENT WITNESS HERE *

DEFENDANT/INDEMNITOR: SIGN HERE *