Only the filed or approved premium and charges expressly permitted by Florida law may be collected. Itemize all money and collateral received and provide any separate receipt required by law or the surety.

For value received, the undersigned promises to pay the unpaid premium balance shown above to the Agency, without interest unless separately stated and lawful, according to the schedule below. This note does not authorize any fee, expense, collection charge, or deduction prohibited by Florida law. Payments shall be credited to this file number.

APPLICATION AND AUTHORITY

I request that the Agency and the named Surety execute the bond described on page 1. I certify that the information supplied by me is true, complete, and provided to induce issuance of the bond.

INDEMNITY

I jointly and severally indemnify and hold harmless the Agency and Surety from actual losses, bond forfeitures, judgments, court costs, and reasonable expenses lawfully incurred because of this bond or a breach of this agreement, subject to Florida law and the terms of the applicable surety agreement.

APPEARANCE AND COOPERATION

I will use reasonable efforts to ensure the Defendant appears whenever required, complies with every court and bond condition, keeps the Agency informed of current residence, employment, telephone number, and email, and promptly advises the Agency of any arrest, violation, travel, or address change.

COLLATERAL

Any collateral is received in trust for the Surety, shall be separately documented, and may be applied only as permitted by law. Except for a promissory note or indemnity agreement, collateral must be returned after termination of liability, less only lawful deductions. A separate collateral receipt or schedule must identify the property and its condition.

SURRENDER / CANCELLATION NOTICE

The Agency and Surety may seek cancellation, surrender, or recommitment only as allowed by the bond, Florida law, and court procedure. The Defendant will be provided any statement or notice required by law. The Agency does not promise that a bond will remain in force regardless of breach or increased risk.

DEFAULT AND COLLECTION

Failure to make a promised payment or perform a material obligation is a default. The Agency may pursue lawful remedies. No attorney fee, collection cost, interest, or other charge is owed unless enforceable under applicable law and expressly authorized in writing.

ELECTRONIC TRANSACTIONS

I agree to conduct this transaction electronically. My typed, drawn, clicked, or otherwise electronically adopted signature is intended to authenticate this entire two-page agreement. I may download or receive a complete copy. The Agency should retain an audit record showing the file number, document version, signer identity method, date/time, IP/device data when available, delivery history, and a tamper-evident document hash.

ENTIRE AGREEMENT / ONE SIGNATURE

Pages 1 and 2, together with any attached collateral receipt, payment schedule, court notice, and approved surety forms expressly incorporated by file number, constitute the agreement. My single signature below applies to the entire document. No oral statement changes it. Any unenforceable provision shall be limited without invalidating the remainder.

Bond restrictions and conditions are listed on page 1. The Agency powers concerning cancellation, surrender, and recommitment are summarized above. For complaints or inquiries, contact the Florida Department of Financial Services, Division of Consumer Services, using the current contact information published by the Department. The signer acknowledges receipt of a complete copy of this agreement and any separate receipt for money or collateral.

OPERATIONAL STATUS

Agency confirms that Florida counsel and the named insurer/surety have approved this form for agency use. Use remains subject to current Florida law, insurer/surety procedures, court requirements, and any transaction-specific notices or receipts.

References: Fla. Stat. ch. 648, including ss. 648.33, 648.44, 648.442, 648.4425; Fla. Stat. s. 668.50; and applicable Fla. Admin. Code ch. 69B-221.