Full Indemnitor Application form – TRAVIS COUNTY

Full Indemnitor Application Form
Travis County

Step 1 of 12

INDEMNITOR APPLICATION AND AGREEMENT

You, the undersigned indemnitor (“Indemnitor” or “you”), hereby represent and warrant that the following declarations made and answers given are true, complete and correct and are made for the purpose of inducing Lexington National Insurance Corporation (“Surety”) to issue, or cause to be issued, bail bond(s) or undertaking(s) (singularly or collectively the “Bond”) for FIRST - MIDDLE - LAST NAME (“Defendant”), using power of attorney (if known) , in the total amount of Dollars ( DOLLARS FIELD) in the IN THE FIELD Court of COURT OF FIELD

Full Name (First, Middle, Last)(Required)

Dollars

in the

Court of

Indemnitor Name and Address

Full Name(Required)

AKA (Also Known As)

Home Phone

Cell Phone(Required)

Work Phone

Email(Required)

Facebook User Name

Other Social Media

Current Home Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

How Long?(Required)

Rent or Own?(Required)

Rent

Own

Landlord/Mortgage Holder(Required)

Former Home Address(Required)

Street Address

How Long?

Rent or Own?

Rent

Own

Landlord/Mortgage Holder

Personal Description

Date of Birth(Required)

Month

Day

Year

Place of Birth:(Required)

Race

Gender(Required)

Male

Female

Social Security(Required)

Driver’s License(Required)

Issuing State(Required)

How Long in U.S.?

U.S. Citizen(Required)

Yes

Nationality

Alien

Additional Notes:

Employment

Employer(Required)

Position

How Long?(Required)

Employer Address(Required)

Street Address

Supervisor’s Name

Local

Union

Military: Branch

Active

Yes

Discharge Date

Marital Status

Status(Required)

Married

Divorced

Separated

Widowed

Single

Cohab

Spouse/Partner's Name(Required)

How Long Married/Together

Address (if different)

Street Address

Social Security

Home Phone (if different)

Cell Phone(Required)

Work Phone

Employer(Required)

Position

How Long

Vehicle

Year(Required)

Make(Required)

Model(Required)

Color(Required)

Plate(Required)

State(Required)

Where Financed

Amount Owed

References

Relationship(Required)

Name(Required)

Address(Required)

Street Address

Employer

Home Phone(Required)

Cell Phone(Required)

Work Phone

Relationship 2(Required)

Name 2(Required)

Address 2(Required)

Street Address

Employer 2

Home Phone 2

Cell Phone 2(Required)

Work Phone 2

Relationship 3(Required)

Name 3(Required)

Address 3(Required)

Street Address

Employer 3

Home Phone 3

Cell Phone 3(Required)

Work Phone 3

Financial Statement/Credit Information

Cash on hand

Cash in bank

Real Estate Value

Real Estate Mortgage

In whose name is title

Monthly salary or wages(Required)

Notes

Additional Notes

THIS INDEMNITY AGREEMENT (“Agreement”) is entered into between you, the undersigned Indemnitor, and Surety through Surety’s duly appointed independent bail producer referenced below (“Producer”).

1.You will have Defendant appear in any court required in connection with the Bond at the times stated in the Bond and all other times as may be ordered by the court.

2. You, jointly and severally (together and separately) with any other indemnitor, shall indemnify the Surety and keep the Surety indemnified and hold it harmless from and against any and all losses, demands, liabilities, fees and expenses relating to, or arising out of, Surety’s issuance or procurement of the Bond, including, but not limited to the following: (a) the principal amount of any forfeiture of, or judgment on, the Bond, plus any related court costs, interest and legal fees incurred, (b) a fugitive recovery fee if there is a forfeiture of the Bond (which fee is typically ten percent of the amount of the Bond for an in-state recovery, plus any out of pocket expenses), (c) any and all extradition costs that may be incurred to apprehend and return the Defendant, and (d) if a collection action is required, reasonable and actual attorneys’ fees plus any and all other costs, expenses and/or assessments that may be incurred as a result of any forfeiture of the Bond subject to applicable law (if any) as stated in an attached addendum. The voucher, check or other evidence of any payment made by Surety or Producer, by reason of such suretyship, shall be conclusive evidence of such payment in any lawsuit against you both as to the propriety of such payment and as to the extent of your liability to Surety for such payment. Further, you will, upon demand, place with Surety the requisite funds to meet any such claim, demand, liability, attorneys’ fees, expense or judgment, whether that demand is made before or after Surety has paid or advanced such funds.

3.Subject to applicable law (if any) as stated in an attached addendum: (a) any property or collateral you deposit is deposited as security for the payment of any and all monies and sums due to Surety or Producer, including all liability, demands, damages, judgments, interest, attorneys’ fees and costs suffered, sustained, made or incurred by Surety or Producer on account of, arising out of or relating to the Bond and transactions contemplated thereby (including, without limitation, the items referenced in Paragraph 2 above), your failure to comply with the terms and conditions of this Agreement, and any and all debt or other obligations arising out of or evidenced by any agreement executed by Defendant, you or any other indemnitor for the benefit of Surety or Producer (“Liabilities”); and (b) if you grant the Surety a lien or a security interest in any property or collateral to enforce the obligations contained in this Agreement, and if you do not perform all of your obligations in this Agreement, you authorize the Surety to (i) apply or sell any collateral security you deposited to reimburse the Surety for any and all Liabilities of any kind or nature, (ii) hold, apply or sell the collateral, or any part thereof, to protect or reimburse the Surety by reason of the execution at any time of any other bond for or on behalf of you or Defendant, and (iii) apply and sell the collateral for the purpose of placing the Surety in cash funds or protecting the Surety against any claim, demand or loss under the Bond or any other bond executed on your or Defendant’s behalf. Subject to applicable law (if any) as stated in an attached addendum, the Surety may make any such sale, at its discretion, at public or private sales, and without demand, notice or advertisement of the time and place of said sale, and also with the right to purchase said collateral at such sale or sales, freed and discharged from any equity or redemption.

4. The Surety shall not be liable for the depreciation of any collateral or for any interest thereon. In the event of depreciation of the collateral, or any part thereof, or of any collateral which may be hereafter deposited with the Surety for its protection, upon request of the Surety, you shall provide the Surety with additional and satisfactory collateral so that the total market value of the collateral shall, at all times, be equal to the market value of the collateral at the time of its initial deposit. Subject to applicable law (if any) as stated in an attached addendum, if you fail to deposit such additional collateral, the Surety shall have the full right, power and authority, without further demand or notice, to sell, assign and deliver the whole or any part of such collateral, substituted collateral, or additional collateral, at public or private sale, at its option, and without demand, notice or advertisement, and also with the right to purchase said collateral at any such sale, freed and discharged from any equity or redemption.

5. If a confession of judgment is taken in connection with the Bond, the Surety shall have the right to enter and file the same at any time, and such judgment shall be a lien and entitled to a preference against any of your property, whether or not the Surety is indemnified at the time of the filing or entry of such judgment. In case a confession of judgment is filed by the Surety against you, the judgment entered shall be effective and available to the Surety against you not only in connection with the Bond but also in connection with any other bond that may have been written by the Surety in which you are either the indemnitor or defendant.

6. You acknowledge and agree that the Surety may foreclose any or all of the liens and security interests arising out of the transactions relating to the Bond or this Agreement, or exercise any of its rights or remedies under this Agreement, or take any combination of such actions, without waiving any other right or remedy. Failure to exercise any rights or remedies of the Surety at any one time shall not constitute a waiver of the right to exercise them at any other time. Any security or collateral you give may be substituted, subordinated, or released by the Surety without affecting any other rights. The Surety shall not be obligated to enforce its rights against any security or collateral prior to enforcing its rights against you or any other indemnitor.

7. Subject to applicable law (if any) as stated in an attached addendum, the Surety will return the collateral to you when all of the following are satisfied: (i) the Surety receives competent written legal evidence satisfactory to the Surety (for example, written notice from the court) of the Surety’s discharge or release from all liability under the Bond; (ii) there are no outstanding Liabilities of any kind arising out of or relating to the Bond; (iii) there are no other outstanding bonds or obligations executed by, for or on behalf of you or Defendant in connection with which the Surety may deem it advisable to retain such collateral for its protection; and (iv) upon the Surety’s request, you shall have executed and delivered to the Surety a general release upon the Surety’s return of the collateral to you. If the Surety deems it necessary to make any outlay to protect any collateral or security in its possession, whether the same be real or personal property, you authorize the Surety to do so, and you agree to indemnify and reimburse the Surety for any such outlay as in the judgment of the Surety may be necessary to protect its collateral or security, including payment of taxes or liens or mortgages and any attorneys’ fees or service fees for time spent and/or special services rendered.

8. The Surety shall have the right to transfer and/or assign, in whole or in part, its rights and obligations in this Agreement, and/or in the Bond to the Producer or any other person or entity (“Assignee”) without notice to or consent from you. Subject to any limitations imposed upon Assignee by the Surety, Assignee shall have the right to enforce in any action, proceeding or otherwise any of the Surety’s rights herein or arising out of any of the transactions contemplated hereby, and you shall not, and expressly waive any right to, assert the claim or defense that Assignee does not have the right to enforce such rights in any such action, proceeding or otherwise. If more than one bond is made or has been made for the Defendant, then this Agreement shall extend to and cover all those bonds and the terms of this Agreement shall apply to each bond individually or as a group.

9. This Agreement and all documents that are executed in connection with this Agreement set forth all the terms of the agreement between the Surety and you. All statements, representations, promises, agreements, and affirmations made by the Surety and its producers and employees prior to or contemporaneously with the execution of this Agreement are contained within this document, and unless they are specifically set forth in this Agreement are of no force or effect whatsoever in determining the rights and liabilities of the Surety and you. You further agree to execute and be bound by any other future documents necessary to carry out and effectuate this Agreement.

10. You hereby acknowledge and agree that neither the Surety nor its Producer has recommended or suggested any specific attorney or firm of attorneys to represent the Defendant in any capacity.

11. This Agreement may not be terminated or modified orally. All modifications and terminations of this Agreement, including any release of your liability hereunder, must be in writing and signed by the Surety and you.

12. To the maximum extent permitted by applicable law, you hereby waive any and all rights you may have under federal law (including, but not limited to, Title 28 Privacy Act-Freedom of Information Act, Title 6, Fair Credit Reporting Act) and any local or State law relating to Surety’s obtaining, and you consent to and authorize Surety to obtain, any and all private or public information and/or records concerning you from any party or agency, private or governmental (local, state, federal), including, but not limited to, credit reports, Social Security Records, criminal records, civil records, driving records, tax records, telephone records, medical records, school records, worker compensation records, and employment records. You further authorize, without reservation, any party or agency, private or governmental (local, state, federal), contacted by Surety to furnish in accordance with applicable law any and all private and public information and records in their possession concerning you to the Surety and direct that a copy of this document shall serve as evidence of said authorization. You irrevocably grant to surety and its producers, agents and representatives the right to enter your residence or other property owned or occupied by you or Defendant without notice, at any time, for the purpose of locating, arresting, and returning to custody the Defendant, and subject to applicable law, you waive any and all causes of action in connection therewith including, without limitation, torts of trespass and false imprisonment.

13. You agree that Surety may attach a location tracking device on any vehicle owned or driven by you, at any time, without notice,and monitor the location of the vehicle through any available technology. You further agree that Surety may use location technologies to locate your wireless device at any time during the period of Defendant’s bail and any applicable remission period, and the Bond is conditioned upon your full compliance with the following terms and conditions: (a) Surety, at its discretion, will use network-based location technologies to find you; (b) this is the only notice you will receive for the collection of your location information; (c) Surety will retain location data only while the Bond is in force and during any applicable remission period; (d) Surety will disclose location information only to the courts as required by court order; (e) Surety and its licensed producers, designees and representatives will be the only persons with access to your location information; (f) YOU WILL NOT HAVE THE OPTION TO OPT-OUT OF LOCATION USE OR TRACKING DURING THE BAIL PERIOD; and (g) all questions relating to location capability should be directed to Surety.

14. In the event any provision herein shall be deemed to exceed any applicable state or federal law, then such provision shall automatically be deemed to have been revised to comply with such law so as to provide the Surety with the maximum protection from any loss or liability. The invalidity or unenforceability of any provision herein (or portion thereof) shall in no way effect the validity or enforceability of any other provision (or portion thereof).

15. You have not been paid to sign this Agreement. You have read the above contract, understand it and agree to fulfill ALL of the provisions therein.

IMPORTANT FRAUD WARNINGS

ALABAMA RESIDENTS - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

ARKANSAS RESIDENTS - Any person who knowingly presents a false or fraudulent claim for payment for a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

FLORIDA RESIDENTS - Any person who knowingly or with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

LOUISIANA, RHODE ISLAND & WEST VIRGINIA RESIDENTS - Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

MAINE, TENNESSEE, VIRGINIA & WASHINGTON RESIDENTS - It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

MARYLAND RESIDENTS - Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NEW JERSEY RESIDENTS - Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NEW MEXICO RESIDENTS - ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

NEW YORK RESIDENTS - 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 fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

OHIO RESIDENTS - Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

OKLAHOMA RESIDENTS - WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

PENNSYLVANNIA RESIDENTS - 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 fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Agreement and Signature

Digital Signature Field for Indemnitor(Required)

Digital Signature Field for Witness

Witness Name

Date

Month

Day

Year

THIS FORM NOT FOR USE IN COLORADO

RULES AND REGULATIONS

You are required to adhere to and comply with all roles and conditions set forth in this agreement conceding the bail bond(s) to which ASAP Bail Bonds has posted Surety on your behalf regarding the charges of _________________________________on bond(s) dated_______________day of__________________

1.MANDATORY CHECK INS ARE ON MONDAYS. YOUWILL BE SENT AN EMAIL FROM (Gary at Bail Books) THIS EMAIL WILL CONTAIN A LINK TO DOWNLOAD THE APP FOR ANDROID OR APPLE USERS. IT WILL ALSO CONTAIN A PERSONAL PIN THAT IS REQUIRED TO SET UP YOUR ACCOUNT. ALL CHECK-IN’S MUST NOT BE CHANGED OR ALTRED IN ANYKIND OF WAY.BONDS 7,500 OR MORE ARE REQUIRED TO CHECK IN MONDAYS AND THURSDAYS.

2.During the term of the bond ($) you may not leave the county of your residence, the State of Texas, or the United States without prior express permission of A.S.A.P. Bail Bonds.

3. You must notify A.S.A.P. Bail Bonds within 4 hours of any changes of your employment, home address, or phone numbers during the term of the bond(s).

4. Starting on ______________,. You must pay_______________________________________ every _____________, to A.S.A.P. Bail Bonds until your account is paid in full. Total fee _________

5. THERE WILL BE A $25.00 LATE FEE ASSESSED IF YOUR PAYMENT GOES 10 DAYS PAST DUE AND $5.00 PER DAY THEREAFTER.

6. ALL ACCOUNTS MUST BE PAID IN FULL BEFORE THE DISPOSAL OF YOUR CASE,

7. A representative of A.S.A.P. Bail Bonds may, at anytime contact you by phone or in person, at home or your place of employment during the term of the bond (s).

8. Failing to comply with the above regulations, providing false information, or being arrested, or placed under arrest during the terms of the bond (s) are grounds for A.S.A.P. Bail Bonds to request to be released from the bond(s) and warrant(s) being issued for your arrest. A.S.A.P, Bail Bonds shall not return any collateral/security if the bond (&) are released under these circumstances.

9. Bond jumping is a criminal offense. You may be charged with Bond jumping if you fail to appear in court as required during the term of the bond(s). A.S.A.P. Bail Bonds will not return any collateral/security if you fail to appear in court as required.

10. I understand the requirements set forth above and I,INDEMNITOR NAME FIELD ,hereby authorize A.S.A.P. Bail Bonds or its representatives to contact, investigate, and/or obtain information from my employer (s), credit references, medical facilities, and/or Credit Bureaus for a period of 2 years from the date of this document to insure my appearance in court.

Case Number

Court

PROMISSORY NOTE

Promise To Pay Holder of This Note on Demand
For valuable consideration, the receipt und sufficiency of which is hereby acknowledged, on demand, we and each of us (hereinafter called Principal), jointly and severally, promise to pay to Derrick Dixon. d/b/a ASAP Bail Bond Company in his capacity as an agent of Lexington National Insurance Corporation. or bearer (herein called Holder), the sum of $ ____________ , in US Dollars, together with interest at the rate of ten (10) percent per annum on the principal sum twice the amount of bond from the ______________, payable at: ______________________________

Waiver of Rights by Principal
By signing this Note, each Principal of this Note expressly waives demand, grace, notice to intent to accelerate, notice of acceleration, protest, presentment for payment, and further agrees that this Note may be renewed, and the time for payment extended without notice, and without releasing any of the parties.

All Costs of Collection Shall Be Paid by Principal on Demond
Each Principal of this Note shall pay on demand all costs of collections, legal expenses, and attorney's fees incurred or paid by the Holder in collecting or enforcing this Note. A waiver on any one occasion shall not be construed as a bar to or waiver of any right or remedy on any future occasion.

Definitions
As used in this Note, this term "Principal" means each of the undersigned. If this Note is signed by more than one in the capacity of Principal, it shall be the joint and several liabilities of these persons. The term "Holder" means the Payee or other endorsee of this Note who is in possession of it, or bearer of this Note.

Before me, the undersigned authority, appeared ______________________ known to me to be the person(s) who(s) name(s) subscribed to the foregoing instrument, and acknowledged to me be that he/she executed the same for the purposes and consideration therein expressed. Given under my hand and seal of office on this _________ day of ___________________.

PLAIN LANGUAGE CONTRACT

I understand that I have signed legally binding documents.
It is my responsibility to let ASAP Bail Bonds know immediately if I change my address, phone number, or place of employment. It is my responsibility to ensure that the defendant is in court every time he/she is scheduled to be there. It is my _________________ responsibility to contact ASAP Bail Bonds Immediately if the defendant is taken into custody for any reason.

If the defendant misses ANY court appearance for ANY reason, ASAP Bail Bonds can demand immediate payment FROM ME _____________________, for the full bond amount, plus court cost, attorney’s fees, and any costs to place defendant back into custody. ASAP Bail Bonds can sue me to collect these payments in the event I fail to pay fees immediately. ASAP Bail bonds may also add any legal or filing fees to original balance.

I am responsible for any balance due to the account; ASAP may apply any future funds collected to an outstanding balance.

If I use a credit/debit card to set up payment arrangements I understand I must keep ASAP Bail Bonds updated with a valid card. Failure to keep ASAP Bail Bonds updated will resolve possible “Theft of Service” charges.

I understand that I am responsible for the defendant until the case is completely resolved. That means the case has been dismissed or the defendant has been found guilty or not guilty.

If something happens and I decide I do not want to be responsible for the defendant’s bond I can request that ASAP Bail Bonds file the proper paperwork with the court for a fee, but I understand that MY OBlLIGATION does not end until the defendant is in jail or the case is resolved.

Date

Month

Day

Year

Subscribed and Sworn to before me on this _____________ day of ________________.

CREDIT CARD AUTHORIZATION FORM

I, ___________________ , the undersigned, request Derrick Dixon DBA ASAP Bail Bonds and/or Lexington National Insurance to charge $ Charge field USD to my credit/debit card.

Charge

These charges to my card are for the purpose of paying a bail bond fee and or pledging collateral for the benefit of benefit field .

Benefit

I understand and agree if I am charging my credit/debit card for the purposes of pledging collateral, the percentage that the merchant is charged by the credit card company will be deducted from the amount that the bonding company is holding for collateral. I understand when the bail bond is terminated, the collateral will be returned 30 days from the termination date less the merchant’s percentage.

I understand my credit/debit card will be charged whatever fees incurred in the event the defendant fails to show up for court. Fees include but not limit to paying court costs, attorney fees, apprehension fees, etc.

Financial Institution: My card is (check one):

Mastercard

Visa

Discover

Amex

My Credit/Debit card number is

Expiration date

ZIP

Bank information

Financial Institution

Account

Routing

I hear by authorize Derrick Dixon DBA ASAP Bail Bonds and or Lexington National Insurance to process a financial transaction to my credit/debit card and/or ACH Transaction. Should the defendant not report to court as agreed.

Gov. ID# / Exp.