COLLATERAL RECEIPT -

COLLATERAL RECEIPT

Agent

Bankers Insurance Company

Address

P.O. Box 15707

Phone No.

St. Petersburg, FL 33733

Power No. (s)

Bond(s) Amount(s)

Defendant(s)

Defendant Address

Received From

Mailing Address

Received From

Mailing Address

Collateral Received

Collateral maintained in custody of

BondsmanManaging General AgentBankers Insurance Company

For inquiries or complaints contact the Department of Insurance.

Received By.

Date

Printed Name

Said collateral is deposited as security for the payment of any sums which may become due to the Agency or BANKERS INSURANCE COMPANY by the terms of the Bail Bond Agreement executed for the said Bond(s) by the said Depositor and Indemnitors, all of the terms of which are made a part of this receipt by this reference. Collateral will be returned only to depositor. No collateral will be returned until the Court has furnished written evidence the bond has been exonerated and this receipt is returned.

RECEIPT FOR RETURN OF COLLATERAL

The undersigned hereby acknowledges the return of the above described collateral