Office Location

PAYMENT TERMS: I (We) having obtained a surety bond release for:

Name

First Last

and having an unpaid balance hereby agree to Afford-A-Bail Bonds Bondsman:

Bond Amount

Premium Amount:

Down Payment:

Amount Owed:

A surety bail bond agent may enter into a premium financing arrangement with a defendant or any co-signer( s) in which such agent extends credit to such defendant or co-signer(s ). If a surety bail bond agent enters into a premium financing arrangement, such agent shall require (1) the defendant on the bail bond or any co-signer( s) to make a minimum down payment of thirty five percent of the premium due, and (2) the defendant and any co-signer( s) to execute a promissory note for the balance of the premium due. Such promissory note shall provide that such balance shall be paid not later than fifteen months after the date of the execution of the bail bond. In the event that payments against the premium become 60 days delinquent, or if such balance has not been paid in full to the surety bail bond agent by the due date, Afford-A-Bail Bonds reserves the right to revoke bail and the agent shall file a civil action seeking appropriate relief with the court.

This note is due and payable as follows:

The first such payment is due and payable on:

and like installments of:

made on a:

basis thereafter until the

total amount of:

is paid in full.

Pursuant to Connecticut General Statue Section 36a-660c, all outstanding balances may be paid IN FULL no later than 15 months after the execution of this bond. If the principal or indemnitor on this note is more than sixty days in arrears, all outstanding balances must be paid IN FULL immediately. Pursuant to Connecticut General Statue Section 36a-660c, If payment due under this note is more than sixty days in arrears regardless of outcome of case, this agent must file a civil action seeking appropriate relief with the court. No Exceptions. May be collected jointly or individually.

FORMS OF PAYMENT: Check, credit card or money order may be accepted. Some fees apply.

Verification of Current or Previous Employment and/or compensation for:

Employee Name

I authorize Afford-A-Bail Bonds on behalf of my employer to release information relative to my employment.
I authorize the release of the following information (Please check one):

Employment Agreement*

Dates of employment, employment type, emproyment status, position and compensation information.

If l (We) do not fulfill our obligation as set forth above, Afford-A-Bail Bonds may transfer, sell or dispose of any and all security in any manner they may deem necessary to pay any unpaid balance . I (We) understand the value of any security is determined by the amount Afford-A-Bail Bonds can expeditiously obtain from immediate transfer of same. I (We) further agree to remit to Afford-A-Bail Bonds immediately upon demand any deficiency balance there may be by transfer of same. I (We) also understand I (We) are responsible for any and all costs incurred as a result of such transfer. I (We) agree that any security deposited may be held or transferred to indemnify Afford-A-Bail Bonds for any balance owed or that may become owed to them under the bail bonds agreement. I (We) understand I (We) are responsible for any storage fees incurred for the security deposited.

ATTORNEY'S FEES: If this note is given to an attorney for collection or enforcement, or if suit is brought for collection or enforcement, or if it is collected or enforced through probate, bankruptcy, or other judicial proceeding then payer(s) shall pay Afford-A-Bail Bond, all costs of collection and enforcement, including reasonable Attorney's fees and court costs in addition to other amounts due.

Executed On This Day:

By signing I agree to pay any cost that may be incurred for late payments.

For monthly invoice check box

For monthly invoice check box

Payer #1

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Hidden

Do You Agree To Our Electronic Signature Terms?

I Agree

You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action while using any electronic service we offer; or in accessing or making any transactions regarding any agreement, acknowledgement, consent, terms, disclosures or conditions constitutes your signature, acceptance and agreement as if actually signed by you in writing. Further, you agree that no certification authority or other third party verification is necessary to validate your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or resulting contract between you and Afford-A-Bail Bail Bonds. You understand and agree that your e-Signature executed in conjunction with the electronic submission of your application shall be legally binding and such transaction shall be considered authorized by you.

Signature*

SS#*

Current Employer

Position

Supervisor Name

Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Current Banking Institution

Mail payments to: Afford-A-Bail P.O. Box 2192 Hartford, CT 06145

This note is due and payable as follows:

Payer #1

Any questions regarding payments please call: 860-7279121

PLEASE READ BEFORE SIGNING THIS DOCUMENT