Form DFS-H2-1542 "Statement of Surrender Form" - Florida

Form DFS-H2-1542 is a Florida Department of Financial Services form also known as the "Statement Of Surrender Form". The latest edition of the form was released in June 1, 2011 and is available for digital filing.

Download an up-to-date Form DFS-H2-1542 in PDF-format down below or look it up on the Florida Department of Financial Services Forms website.

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Download Form DFS-H2-1542 "Statement of Surrender Form" - Florida

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Statement of Surrender Form
This form must be completed at the time of the surrender of a defendant by a bail bond agent with a copy provided to the defendant,
pursuant to §648.4425, Florida Statutes. If a jail has a separate surrender form; this form must be completed and attached to that form.
Defendant’s full name:
Criminal court case number:
Surrender Date:
Reason for surrender:
Please check one of the following:
Bail bond agent physically surrendered defendant
Defendant already in custody on other charges
Will premium be returned?
Yes
No
(If no, explain below)
Was a surrender fee charged?
Yes
No
If yes, state the amount and reason for the fee:
Charge
Date of Bond
Amount of Bond
Power Number
I
I
648,
DO HEREBY CERTIFY THAT
AM A LICENSED AND APPOINTED BAIL BOND AGENT PURSUANT TO CHAPTER
F
. I
LORIDA STATUTES
FURTHER CERTIFY THE SURRENDER OF THE ABOVE LISTED DEFENDANT IS FOR THE REASON
. I
STATED ABOVE
UNDERSTAND THAT WHOEVER KNOWINGLY MAKES A FALSE STATEMENT IN WRITING WITH THE
INTENT TO MISLEAD A PUBLIC SERVANT IN THE PERFORMANCE OF HIS OR HER OFFICIAL DUTIES IS GUILTY OF A
,
§837.06, F
S
.
MISDEMEANOR OF THE SECOND DEGREE
PURSUANT TO
LORIDA
TATUTES
Bail Bond Agent Signature:
Bail Bond Agent Printed Name:
Bail Bond Agent License Number:
Bail Bond Agency Name:
Bail Bond Agency Address:
Signature of Receiving Officer
(if applicable)
Original: Attach to jail surrender form (if applicable)
Copy:
Defendant
Copy:
Bail bond agent’s file
DFS-H2-1542
69B-221.100 (2), F.A.C.
Revised 06/11
Statement of Surrender Form
This form must be completed at the time of the surrender of a defendant by a bail bond agent with a copy provided to the defendant,
pursuant to §648.4425, Florida Statutes. If a jail has a separate surrender form; this form must be completed and attached to that form.
Defendant’s full name:
Criminal court case number:
Surrender Date:
Reason for surrender:
Please check one of the following:
Bail bond agent physically surrendered defendant
Defendant already in custody on other charges
Will premium be returned?
Yes
No
(If no, explain below)
Was a surrender fee charged?
Yes
No
If yes, state the amount and reason for the fee:
Charge
Date of Bond
Amount of Bond
Power Number
I
I
648,
DO HEREBY CERTIFY THAT
AM A LICENSED AND APPOINTED BAIL BOND AGENT PURSUANT TO CHAPTER
F
. I
LORIDA STATUTES
FURTHER CERTIFY THE SURRENDER OF THE ABOVE LISTED DEFENDANT IS FOR THE REASON
. I
STATED ABOVE
UNDERSTAND THAT WHOEVER KNOWINGLY MAKES A FALSE STATEMENT IN WRITING WITH THE
INTENT TO MISLEAD A PUBLIC SERVANT IN THE PERFORMANCE OF HIS OR HER OFFICIAL DUTIES IS GUILTY OF A
,
§837.06, F
S
.
MISDEMEANOR OF THE SECOND DEGREE
PURSUANT TO
LORIDA
TATUTES
Bail Bond Agent Signature:
Bail Bond Agent Printed Name:
Bail Bond Agent License Number:
Bail Bond Agency Name:
Bail Bond Agency Address:
Signature of Receiving Officer
(if applicable)
Original: Attach to jail surrender form (if applicable)
Copy:
Defendant
Copy:
Bail bond agent’s file
DFS-H2-1542
69B-221.100 (2), F.A.C.
Revised 06/11
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