Payment Agreement Form - Connecticut Bonding CO LLC

Basic Information

Name

First Last

Bond Amount:

Premium Amount:

Down Payment:

Amount Owed:

A surety bail bond agent may enter into a premium financing arrangement with a defendant or any co-signer( s) in which such agent extends credit to such defendant or co-signer(s ). If a surety bail bond agent enters into a premium financing arrangement, such agent shall require (1) the defendant on the bail bond or any co-signer( s) to make a minimum down payment of thirty five percent of the premium due, and (2) the defendant and any co-signer( s) to execute a promissory note for the balance of the premium due. Such promissory note shall provide that such balance shall be paid not later than fifteen months after the date of the execution of the bail bond. In the event that payments against the premium become 60 days delinquent, or if such balance has not been paid in full to the surety bail bond agent by the due date, Connecticut Bonding CO LLC reserves the right to revoke bail and the agent shall file a civil action seeking appropriate relief with the court.

This note is due and payable as follows:

The first such payment is due and payable on:

and like installments of:

made on a:

Weekly

Bi-weekly

Monthly

total amount of:

is paid in full

Pursuant to Connecticut General Statue Section 36a-660c, all outstanding balances may be paid IN FULL no later than 15 months after the execution of this bond. If the principal or indemnitor on this note is more than sixty days in arrears, all outstanding balances must be paid IN FULL immediately. Pursuant to Connecticut General Statue Section 36a-660c, If payment due under this note is more than sixty days in arrears regardless of outcome of case, this agent must file a civil action seeking appropriate relief with the court. No Exceptions. May be collected jointly or individually.

FORMS OF PAYMENT:

Check, credit card or money order may be accepted. Some fees apply. Verification of Current or Previous Employment and/or compensation for:

Employee Name

First Last

Executed On This Day:

Payer

Name

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone

Social Insurance #

Employment

Current Employer

Position

Supervisor Name

First Last

Phone

Address of Employment

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Current Banking Institution

Mail payments to: Connecticut Bonding Company LLC - 1266 E Main St, Stamford, CT, 06902-3546, United States

Signature