Step 1 of 3 33% Section AName of Alien First Last Power #Penal SumCase #Date Bond Posted Date Format: MM slash DD slash YYYY Place Bond PostedName of Agent First Last Section BIs the Alien being detained in California?*YesNoDoes any person paying at least 50% of the premium reside in California?YesNoDoes any person providing collateral to guarantee over 50% of the bond reside in California?YesNoIs the Undersigned Agent located in California?YesNoBy answering “no” to each question in Section B, enter your name here to indicate that your answers in Sections A and B are truthful to the best of your knowledge and belief First Last Section CThe Undersigned declares under penalty of perjury and affirms as follows: I was involved in the solicitation and/or negotiation preliminary to the execution of the above referenced bond, and/or the execution of the above referenced bond, and/or transactions of matters subsequent to the execution of the above referenced bond. I hold a valid California Fire & Casualty License. I have not charged a rate or other charge in excess of the rates and other charges that have been approved by the California Department of Insurance for Lexington National Insurance Corporation. I have not paid a commission or referral fee related to the above captioned bond to anyone who does not hold a California Fire & Casualty License. The answers set forth in Sections A and B are truthful to the best of my knowledge and belief. Name of Agent First Last
