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 This day of , 20 Witness Sign Print name Depositor Sign Print name Depositor Sign Print name