Fcs

Omnibus Receipt

Description of Bail Bond

Receipt #

This Receipt is for (check all that apply):

Money / PaymentPremiums / Fees / ExpenseCollateralOther

Defendant Information

Defendant Last Name

Defendant First Name

Defendant Middle Name

Bond Amount ($)

Case Number (if known)

Court Name

Power Number

Receipt Date

Receipt Date

This receipt is acknowledged on the above date for the money, property and/or documents described below.

Payment Details

Total Amount ($)

Payment Method (check all that apply):
CashCheckMoney OrderCredit Card

Supplemental description of documents or items tendered:

Premiums, Fees & Expense

Check and fill amounts as applicable.

Bail Premium Amount ($)

Jail or Court Posting Fee Amount ($)

Installment Payment Amount ($)

Premium Refund Amount ($)

Bail Recovery, Cost/Expense Amount ($)

Collateral Storage, Cost/Expense Amount ($)

Refund Overpayment Amount ($)

Collect Underpayment Amount ($)

Receipt From / To

RECEIPT FROM

The person receiving money, property or documents and who provides this receipt as documentation.

Name

Phone

Email

Address

RECEIPT TO

The person tendering money, property or documents and who provides this receipt as documentation.

Name

Phone

Email

Address

Collateral

If applicable, check more than one box:

Promissory NoteTrust DeedRequest for Release of Trust DeedTitle DocumentOther Property

Collateral Action:

Collateral – Initial TenderCollateral – IncreaseCollateral – DecreaseCollateral – Substitution/ExchangeCollateral – Refund of MoniesCollateral – Return of PropertyCollateral – Document Cancellation

Collateral – Condition / Description

Reason (if applicable)

Check Reason:
Supplemental receipt during initial underwritingBond Not Posted/Cancelled/ReturnedBond RevokedFTABond ForfeitedRemission GrantedBond ExoneratedRefund OrderOther

If “Other”, describe:

Real Property as Collateral

Is real property being taken as collateral?
[radio* real-property-collateral use_label_element "Yes" "No"]

Indemnitor & Producer

Indemnitor Name – Print

Indemnitor Name – Signature

Indemnitor Name – Print (2)

Indemnitor Name – Signature (2)

Producer Name – Print

Producer Name – Signature

Bail Producer Stamp / Details (if needed)