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United States Fire Insurance Company (Surety)

11490 Westheimer Rd., Suite 300 • Houston, TX 77077

P.O. Box 2807 • Houston, Texas 77252-2807

(713) 954-8100 • (713) 954-8389 FAX

Form #1

DEFENDANT BAIL BOND APPLICATION AND AGREEMENT

You, 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, a bail bond or undertaking for you, using power of attorney number(s) (if known):

Short answer

in the total amount of

in the

Court of

Short answer

("Bond").

DEFENDANT'S NAME AND ADDRESS

Name (First, Middle and Last):

Nickname/Alias:

Home Phone #:

Cell Phone #:

Work Phone #:

Email Address:

Social Media Accounts:

Current Home Address:

How Long?:

Rent or Own?:

Rent

Own

Landlord:

Former Home Address:

How Long?:

Rent or Own?:

Rent

Own

Landlord:

How long resided in current city?

How long in current state?

How Long in the U.S.?