Bonds Southeast, Inc. | Court Bond Application

Bonds Southeast, Inc.
Contract & Commercial Surety Bonds
1030 17th Avenue South
Nashville, TN 37212
(615) 321-9700
Toll Free: 1-877-992-6637
Fax: (615) 321-9702

Court Bond Application
First year's premium is fully earned at issuance

Instructions:
1.) Please complete all necessary sections of this application and PRINT or SUBMIT ONLINE.
2.) FOR ALL BONDS IN EXCESS OF $20,000, include applicant’s current signed and dated financial statement.
3.) PROVIDE A BREAKDOWN OF ASSETS AND LIABILITIES for the Estate.
4.) Please provide a copy of ALL court documents pertaining to the appointment.

Name	(As it appears on the bond)
Address	Street CIty State Zip
Phone Number	( ) (Of applicant)
Social Security Number of Tax ID#
Is the Applicant a U.S. Citizen?	Yes No
Nature of Business
Date Business Started

If Applicant is a business, list:

Names of All Owners	Residence Address	Social Security #'s	% Ownership
		- -	%
		- -	%
		- -	%
		- -	%

Type of Bond Required
Bond Amount	$
Attorney's Name
Attorney's Address	Street CIty State Zip
Attorney's Phone	( )
Case #
Undertaking Statute #	State:
Bonds to Be Filed in	Court of , State of
Court Address	Street CIty State Zip

PLEASE COMPLETE THIS SECTION FOR OBLIGEE OTHER THAN COURT: (i.e. Lien Bond Obligations)

Obligee Name
Obligee Address	Street CIty State Zip

EXPLANATION OF THE CASE:

Have You Ever

Failed in Business?	Yes No	Filed Bankruptcy?	Yes No
Had any prior or have any pending leins?	Yes No	Had any prior or have any pending lawsuits?	Yes No
Had a claim aginast a surety bond?	Yes No

GENERAL AGREEMENT OF INDEMNITY

The Undersigned and each of them, for himself, his heirs, legal representatives, successors and assigns, hereby represent that the statements made herein as an inducement to the Surety to execute the bond applied for herein are true, authorizes and requests any financial institution, individual, or corporation including any prior sureties or credit reporting agencies to furnish any information requested by the Surety concerning any transaction with Undersigned and, in consideration of the execution of the Surety of the said bond or any renewal, continuation, modification thereof (hereinafter called Bond), agrees:

To pay the Company in advance the initial premium and thereafter pay in advance such additional premiums as may become due until the company is legally discharged and released of all liability under said bond and evidence of such discharge and release satisfactory to it is delivered to the Company.
That the Undersigned shall indemnify the Company from and against all claims, demands, losses, liability, damages (including punitive and exemplary), costs, charges, attorneys' fees, expenses, suits, orders, judgments, or adjudications whatsoever which the Company may at any time sustain or incur or be put to by reason or in consequence of the Company's having executed or procured the execution of said bond, increasing or having increased a bond penalty by rider, making any investigation on account of said bond, defending or prosecuting any action, suit or other proceeding which may be brought in connection therewith, enforcing any of the agreements contained herein, procuring a release from said bond, or canceling said bond in accordance with any cancellation provision therein contained.
That the Company shall have the right and is hereby authorized, but not required, to pay, adjust, settle or compromise any claim, demand, suit or judgment upon said bond, and the voucher or other evidence or such payment, adjustment, settlement or compromise, whether the Company was liable therefore or not, shall be prima facie evidence of the fact and extent of the liability of the Undersigned.
That in the event the Company is required to reserve from its assets an amount to cover any claim, demand, liability, expense, suit, order, judgment or adjudication by reason of a breach or default of the said bond, the Undersigned will immediately, on demand, deposit with the Company in current funds an amount equal to such reserve as collateral security to be held by the Company for its indemnification without derogation of any other rights to indemnity afforded by this instrument.
That separate suits may be brought to recover hereunder as causes of action shall accrue and the bringing of suit or the recovery of judgment upon any cause of action shall not prejudice or bar the bringing of other suits upon other causes of action, whether therefore or thereafter arising.
That it is expressly understood and agreed by the Undersigned that any and all other rights which the Company may have or acquire against the Undersigned and/or others under any such other or additional agreement of indemnity or collateral shall be in addition to, and not in lieu of, the rights afforded the Company under this agreement.
That these covenants shall be jointly and severally binding upon the Undersigned, their respective heirs, executors, administrators, successors, and assigns.
The Undersigned agrees a facsimile copy of this agreement shall be considered an original and shall be admissible in a court of law to the same extent as the original agreement

Today's Date
PRINCIPAL NAME	(President)
ATTEST	(Secretary)
Individual Indemnitors	(name) (name) (name) (name)
Spouse Indemnitors	(name) (name) (name) (name)

“Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any act material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.”

Personal Financial Statement

Statement of Financial Condition As Of
Name of Applicant
Applicant's Social Security Number	- -
Applicant's Date of Birth
Name of Spouse
Spouse's Social Security Number	- -
Spouse's Date of Birth
Residential Address	Street CIty State Zip
Home Phone Number	( )

ASSETS

Cash in Banks
Notes Receivable
Accounts Receivable
Stocks/Bonds/Securities
Real Estate (Residence)
Real Estate (Investment/Other)
Cash Value Life Insurance
Personal Property
Other Assets
TOTAL ASSETS

LIABILITIES

Loans Payable (Banks)
Notes Payable
Accounts Payable
Taxes Payable
Mortgages Payable
Other Liabilities

TOTAL LIABILITIES
NET WORTH
Total Net Worth & Liabilities

INCOME

Applicant's Salary	$
Applicant's Bonus/Other	$
Spouse's Salary	$
Spouse's Bonus/Other	$
TOTAL INCOME	$

SUPPLEMENTARY SCHEDULES OF ASSETS & LIABILITIES
(NOTE: All data listed above must appear in the appropriate schedules. Insert "NONE" where appropriate.)

CASH IN BANKS:

Name of Bank	Branch / Location	Account #	Amount

NOTES & ACCOUNTS RECEIVABLE:

Debtor #1	Name Address Amount Due Date Pledged? Yes No Security
Debtor #2	Name Address Amount Due Date Pledged? Yes No Security
Debtor #3	Name Address Amount Due Date Pledged? Yes No Security

STOCKS / BONDS / SECURITIES:

Name of Stock, Bond or Security	No. of Shares	Price/Share	Market Value	Exchange & Call Sign

REAL ESTATE:

Item #1	Location / Description Year Acquired Cost Market Value Monthly Income Monthly Payment Mortgage Balance Mortgage or Lein Holder
Item #2	Location / Description Year Acquired Cost Market Value Monthly Income Monthly Payment Mortgage Balance Mortgage or Lein Holder
Item #3	Location / Description Year Acquired Cost Market Value Monthly Income Monthly Payment Mortgage Balance Mortgage or Lein Holder

CASH VALUE OF LIFE INSURANCE:

Name of Insurance Company	Beneficiary	Face Value	Cash Value	Loans Outstanding

OTHER ASSETS:

Description	Title Holder	Cost	Market Value	Age of Asset

LOANS PAYABLE

Name of Lender	Address	Balance Due	Amount Due in 1 Year	How Secured

ACCOUNTS & NOTES PAYABLE (Including Charge Accounts):

Payable to Whom	Address	Amount	Monthly Payment	Due Date	How Secured

TAXES PAYABLE (State & Federal):

Description	Amount	Date Payment is Due

OTHER LIABILITIES:

Description	Payable To:	Amount	Monthly Payment	Due Date	How Secured

Are you contingently liable or an endorser on any bonds or other obligations?	Yes No
Are you involved in any litigation?	Yes No
Have you filed for bankruptcy in the last 7 years?	Yes No

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