RRR Bail Bond

Agent Name

Application and Indemnity for Bail Bond

Bond #

Bond Date

Defendants Name

Sex

Race

Date of Birth

Court/ATOB Payment Information

Age

Address

Country

City

State

Zip Code

State of: ARKANSAS

Social Security Number

Phone

I, the undersigned, do hereby apply to you to act as my bail in the:

District or Circuit

Court in The County of

Wherein I am charged with the offense(s) of:

Offense

Amount of Bond

Court Date/Time

• I further agree that you, as my bail, shall have control and jurisdiction of me during the term for which the bond is executed and that I further agree and understnad that I will not leave the jurisdiction of the court without permission of the bondsman, nor commit any further offenses.

Agent Collected Fee that gets bill to the office:

Paid:

Premium & Fees:

Cash/Check/Credit Card: Select Option Cash Check Credit Card

Credit Card Approval Number

Balance Due:

Condition of Bai

Bond #

VIOLATIONS OF ANY RULES AND REGULATIONS LISTED BELOW WILL BE GROUNDS FOR REVOCATION OF A CLIENTS BOND. 1. All clients will call the bond agent on check-in day by the time listed above 2. All clientn will call the bond agent prior to: a. changing their address or moving to a new location b. the purchase or sale of a vehicle c. the pruchase or sale of property d. the change of employment or unemployment e. leaving your jurisdiction as known by the bonding agent 3. If the client is arrested on other charges while on bond with Triple R Bail Bonds, INc. that clietn will notify the bond agent or the office Triple R Bail Bonds, Inc. at the time that the clietn is arrested and before the client is released from custody. 4. If a client is incarcerated at another detention facility on his/her required court date as per the bond number above Sureities may personally, or through an agent, arrest the offender to surrender him/her, and may purseue him into another state..... APPREHENSION AGREEMENT: Any agent action on behalf of Triple R Bail Bonds, Inc. charges a minimum of $30 per hour for apprehension, plus any other expenses incurred..... SURRENDER AND ARREST OF PRINCIPAL BY BONDSMAN BY BONDSMAN TAYLOR vs. TAINTER Sureties may personally, or through an agent, arrest the offender to surrender him,, and they amy pursue him into another state..... Principal is regarded as delivered to the custody of the sureties who may seize him and deliver him up, and if that cannot be done at once.. AUTHORITY TO RELEASE RECORDS TO:

Authority To Release Records To:

I/We undersigned do hereby authorize each person, partnership, corporation, governmental body or court on possession of any and all records concerning.

Client Name

Promissory Note

Bond #

On the date of forfeiture above named promise(s) to pay Triple R Bail Bonds, Inc. hereinafter referred to as Secured Party, the amount of:

Bond Amount

The value received payable at Triple R Bail Bonds, Inc. at 984 Ash Flat Drive Suite B, Ash Flat, AR 72513... INDEMNITY AGREEMENT: I (Client/Co-Signers) agree to: Hereinafter referred to as "indemintor" in consideration of Triple R Bail Bonds, Inc. hereinafter to the defendant hereby agrees as follows: FULL INDEMNITY: The defendant and Indemnitor will be at all times indemnity and save Surety harmless from and against every claim.... COMPROMISE: Surety shall have the right to pay of compromise any claim, change of expense incurred by the reason of its causing.... OBLIGATION OF THE DEFENDANT: The defendant agrees to remain within the jurisdiction of the court mentions herein.... COLLATERAL SECURITY: The indemnitor and /or defendant has pledged with Triple R Bail Bonds, Inc. the following described collateral to protect....

Collateral

SECURITY AGREEMENT: I/We give you an interest in my (our) property that is described below. This property is hereinafter called collateral: All vehicles, household goods, household items, musical instruments, stocks, bonds, bank accounts, jewerly, guns, boats, sporting equipment, tools, clothing, registered animals, building materials, utility deposits, cameras and equipment and any other items owned by me (us) Specify: All Personal Property and Contents of Current and Future Address Or any additions, replacements or proceeds for the sale of the above collateral. LOCATION: The above collateral is used for personal purposes and will be kept at current or future address of client/co-signers: DEFAULT; I will be in default: 1. if I/We don't make a payment when due or I/We don't fully repay any loan or I/We may have with Triple R Bail Bonds, Inc. REPOSSESSION: If borrower(s) default(s) on payment of this loan or fail to comply with any of the terms of this agreement, the lender shall have all rights...LAW THAT APPLIES: This agreement will be covered by Arkansas Law. If the secured party excuses one default, it does not mean later occurences of default will be excused... I (We) STATE THAT WE HAVE READ THE ABOVE PROMISSORY NOTE, INDEMNITY AGREEMENT AND SECURITY AGREEMENT AND AGREE TO THE TERMS SET OUT THEREIN.

Co-Signer

Co-Signer Address

Apt, suite, etc.

Country

City

State

ZIP Code

Co-Signer Phone

Collateral

Amount of Bail

Client Name

I, the undersigned defendant, acknowledge that I am charged in the above stated court of the above stated county in the state of Arkansas, with the above offenses and that the above warrant # has been issued from the State of Arkansas for my arrest. I waive issuance and service of the warrant provided by law for my extradition from the above state to the State of Arkansas, and I acknowledge to the above Judge of the above court in the above county in the State of Arkansas, that I am willing to return in the custody of any peace officer, bail bondsman or Private Investigator licensed in the State of Arkansas without the issuance and service of any warrant other than the warrant already issued for my arrest. I understand that I have the right to demand that extradition proceedings be initiated and carried our in this matter and I voluntarily waive all extradition proceedings of every kind and character, pursuant to Arkansas Code Annotated Title 16 Practice, Procedures and Courts, Subtitle 6 Criminal Procedure Generally Chaper 94 Extradition: Subchapter 2 Uniform Criminal Extradition Act - 16-94-214 - Arrest without Warrant: Which States: 16-94-214: (a) The arrest of a person may be lawfully made also by an officer or a private citizen without a warrant upon reasonable information that the accused stands charged in the courts of another state with a crime punishable by death or imprisonment for a term exceeding one (1) year; but when so arrested the accused must be taken before a judge or magistrate with all practicable speed and complaint must be made against him or her under oath setting forth the ground for the arrest as in the last section; and thereafter his or her answer shall be heard as if he or she had been arrested on a warrant. (b) Notwithstanding any other law to the contrary, a law enforcement officer shall deliver a person in custody to the accredited agent or agents of a demanding state without the Governor's warrant provided that: (1) Such person is alleged to have broken the terms of his or her probation, parole, bail or any other release of the demanding state; and (2) The law enforcement agency has received from the demanding state an authenticated copy of a prior waiver of extradition signed by such person as a term of his or her probation, parole, bail or other release of the demanding state. The copy shall contain photographs, fingerprints or other evidence properly identifying such person as the person who signed the waiver. I further realize that I am entitled to sue out a write of habeas corpus and I further voluntarily waive my rights of the habeas corpus proceeding, all of these matters having been explained to me by the above judge of the above court of the above county, State of Arkansas, I understand that this is not in any way a plea of guilty and that I do not waive any of my rights in the trial of the matter with which I am charged in the State of Arkansas.

HIPPA Privacy Authorization Form

The purpose of this HIPAA Privacy Authorization Form is for Triple R Bail Bonds, Inc. to have access to your medical records in case doctor appointments, hospital stays, or rehab treatments effect your court date. Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164) 1. Authorization I authorize any and all past, present, and future healthcare providers to use and disclose the protected health information described below to Triple R Bail Bonds, Inc. 2. Effective Period This authorization for release of information cover the period of healthcare from this day until the bail bond if satisfied. 3. Extent of Authorization I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or Aids, and treatment of alcohol or drug abuse. 4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation or other purposes as I may direct. 5. This authorization shall be in force and effect until the bail bond is satisfied, at which time this authorization expires. 6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. 7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. 8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Client Name

Date

Total Due

Amount Paid

Balance Due

Name Contact 1

Address Contact 1

Apt, suite, etc.

Country

City

State

ZIP Code

Phone Contact 1

Name Contact 2

Address Contact 2

Apt, suite, etc.

Country

City

State

ZIP Code

Phone Contact 2

Message