Form DFS-H2-1543 "Temporary Bail Bond Agent Employment Report" - Florida

Form DFS-H2-1543 is a Florida Department of Financial Services form also known as the "Temporary Bail Bond Agent Employment Report". The latest edition of the form was released in July 1, 2013 and is available for digital filing.

Download an up-to-date Form DFS-H2-1543 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-H2-1543 "Temporary Bail Bond Agent Employment Report" - Florida

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DEPA
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services - Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
I
NSTRUCTIONS
Tallahassee, FL 32399-0319
This form must be filed at the completion of each month with the Department of Financial Services by the supervising
TEMPORARY BAIL BOND AGENT EMPLOYMENT REPORT
bail bond agent, pursuant to 648.355, Florida Statutes and 69B-221.051, Florida Administrative Code .
Print legibly the name and business address of the temporary bail bond
Temporary Bail Bond Agent:
agent. If it cannot be read; it cannot be processed.
Business information must agree with the information on the agent’s license
N
Business Name:
records and that of the supervising agent.
E
Differences will be reason to return the form for corrections.
Business Address:
X
.
Remember to submit the reports
month to expedite processing
EACH
T
City/State Zip Code:
Failure to send a report to the department within 30 days after the last hour
worked on the form may result in loss of credit for some or all of your hours.
Agency Phone Number:
HOURS WORKED DURING THE MONTH OF:
Month hours were
worked,
20Year
Date
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
WEEKLY
Hours
Hours
Hours
Hours
Hours
Hours
Hours
TOTALS
Week 1
8.0
2.5
10.5
9/1 - 9/2
Week 2
Put the dates of the
6.5
10.0
10.0
10.0
10.0
46.5
9/3 – 9/9
days in the week
being reported
Week 3
8.0
Report the actual hours worked by
(Examples shown)
5.0
8.0
8.0
5.0
12.0
46.0
9/10 – 9/16
the temporary bail bond agent,
Week 4
each day. Only report hours for the
12.0
10.0
10.0
10.0
42.0
9/17 – 9/23
days in the month listed.
Week 5
8.0
8.0
8.0
8.0
8.0
40.0
9/24 – 9/30
I certify the hours recorded above are the actual hours I worked
Under penalty of perjury I certify as required by §648.355(1)(e), F.S.
Temporary Bail Bond Agent
Supervising Bail Bond Agent
as a temporary bail bond agent at this agency, to meet the
that I have verified the hours recorded above as the actual hours
qualifications under §648.355, F.S.
worked as a temporary bail bond agent at this agency by this licensee.
Name:
_________________________
Name:
_________________________
License #:
_________________________
License #:
_________________________
Signature:
_________________________
Signature:
_________________________
Sworn to and subscribed before me this
day of __________,
Sworn to and subscribed before me this
day of __________,
State of F
County of _________________________________
State of F
County of _________________________________
LORIDA
LORIDA
20___ by _________________________
20___ by _________________________
who
is personally known to me, or who
produced
who
is personally known to me, or who
produced
________________________________ as identification.
________________________________ as identification.
Notary Public, State of Florida
Notary Public, State of Florida
Notary’s section used to certify the signatures of the agents.
(Signature)
(Signature)
Signatures not notarized are not approved and the form will be returned.
(Seal)
(Seal)
N
DEPARTMENT USE ONLY
E
S
D
R
T A T U S
A T E
E V I E W E R
Florida Department of Financial Services
Form to be mailed to:
X
Bureau of Licensing
Approved
Larson Building #419
T
Not Approved
200 E. Gaines Street
Tallahassee, Florida 32399-0319
DFS-H2-1543
69B-221.051, FAC
Revised: 7/13
DEPA
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services - Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
I
NSTRUCTIONS
Tallahassee, FL 32399-0319
This form must be filed at the completion of each month with the Department of Financial Services by the supervising
TEMPORARY BAIL BOND AGENT EMPLOYMENT REPORT
bail bond agent, pursuant to 648.355, Florida Statutes and 69B-221.051, Florida Administrative Code .
Print legibly the name and business address of the temporary bail bond
Temporary Bail Bond Agent:
agent. If it cannot be read; it cannot be processed.
Business information must agree with the information on the agent’s license
N
Business Name:
records and that of the supervising agent.
E
Differences will be reason to return the form for corrections.
Business Address:
X
.
Remember to submit the reports
month to expedite processing
EACH
T
City/State Zip Code:
Failure to send a report to the department within 30 days after the last hour
worked on the form may result in loss of credit for some or all of your hours.
Agency Phone Number:
HOURS WORKED DURING THE MONTH OF:
Month hours were
worked,
20Year
Date
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
WEEKLY
Hours
Hours
Hours
Hours
Hours
Hours
Hours
TOTALS
Week 1
8.0
2.5
10.5
9/1 - 9/2
Week 2
Put the dates of the
6.5
10.0
10.0
10.0
10.0
46.5
9/3 – 9/9
days in the week
being reported
Week 3
8.0
Report the actual hours worked by
(Examples shown)
5.0
8.0
8.0
5.0
12.0
46.0
9/10 – 9/16
the temporary bail bond agent,
Week 4
each day. Only report hours for the
12.0
10.0
10.0
10.0
42.0
9/17 – 9/23
days in the month listed.
Week 5
8.0
8.0
8.0
8.0
8.0
40.0
9/24 – 9/30
I certify the hours recorded above are the actual hours I worked
Under penalty of perjury I certify as required by §648.355(1)(e), F.S.
Temporary Bail Bond Agent
Supervising Bail Bond Agent
as a temporary bail bond agent at this agency, to meet the
that I have verified the hours recorded above as the actual hours
qualifications under §648.355, F.S.
worked as a temporary bail bond agent at this agency by this licensee.
Name:
_________________________
Name:
_________________________
License #:
_________________________
License #:
_________________________
Signature:
_________________________
Signature:
_________________________
Sworn to and subscribed before me this
day of __________,
Sworn to and subscribed before me this
day of __________,
State of F
County of _________________________________
State of F
County of _________________________________
LORIDA
LORIDA
20___ by _________________________
20___ by _________________________
who
is personally known to me, or who
produced
who
is personally known to me, or who
produced
________________________________ as identification.
________________________________ as identification.
Notary Public, State of Florida
Notary Public, State of Florida
Notary’s section used to certify the signatures of the agents.
(Signature)
(Signature)
Signatures not notarized are not approved and the form will be returned.
(Seal)
(Seal)
N
DEPARTMENT USE ONLY
E
S
D
R
T A T U S
A T E
E V I E W E R
Florida Department of Financial Services
Form to be mailed to:
X
Bureau of Licensing
Approved
Larson Building #419
T
Not Approved
200 E. Gaines Street
Tallahassee, Florida 32399-0319
DFS-H2-1543
69B-221.051, FAC
Revised: 7/13
DEPA
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services - Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
This form must be filed at the completion of each month with the Department of Financial Services by the supervising
TEMPORARY BAIL BOND AGENT EMPLOYMENT REPORT
bail bond agent, pursuant to 648.355, Florida Statutes and 69B-221.051, Florida Administrative Code .
Temporary Bail Bond Agent:
Business Name:
Business Address:
City/State Zip Code:
Agency Phone Number:
HOURS WORKED DURING THE MONTH OF: ____________, 20____
Date
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
WEEKLY
Hours
Hours
Hours
Hours
Hours
Hours
Hours
TOTALS
Week 1
Week 2
Week 3
Week 4
Week 5
I certify the hours recorded above are the actual hours I worked
Under penalty of perjury I certify as required by §648.355(1)(e), F.S.
Temporary Bail Bond Agent
Supervising Bail Bond Agent
as a temporary bail bond agent at this agency, to meet the
that I have verified the hours recorded above as the actual hours
qualifications under §648.355, F.S.
worked as a temporary bail bond agent at this agency by this licensee.
Name:
_________________________
Name:
_________________________
License #:
_________________________
License #:
_________________________
Signature:
_________________________
Signature:
_________________________
Sworn to and subscribed before me this
day of ___________________,
Sworn to and subscribed before me this
day of ___________________,
State of F
County of _________________________________
State of F
County of _________________________________
LORIDA
LORIDA
20________ by ________________________________________________________________________________________
20________ by ________________________________________________________________________________________
who
is personally known to me, or who
produced
who
is personally known to me, or who
produced
________________________________________________________________________________ as identification.
________________________________________________________________________________ as identification.
Notary Public, State of Florida
Notary Public, State of Florida
(Signature)
(Signature)
(Seal)
(Seal)
DEPARTMENT USE ONLY
Florida Department of Financial Services
Form to be mailed to:
Bureau of Licensing
S
D
R
T A T U S
A T E
E V I E W E R
Larson Building #419
Approved
200 E. Gaines Street
Tallahassee, Florida 32399-0319
Not Approved
DFS-H2-1543
69B-221.051, FAC
Revised: 7/13
DEPA
DEPARTMENT OF FINANCIAL SERVICES
Division of Agent & Agency Services - Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
Safeguard your hours
Employment reports are required to be submitted to the Department of Financial Services no
later than the last day of the month following the month being reported on the form. (See 69B-
221.051(4)(e), Florida Administrative Code).
Failure to submit employment reports each month may result in the loss of credit for the hours
worked as well as administrative action being taken.
For example, the hours worked in January should be submitted to the Department of Financial
Services no later than the end of February of that same year.
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The department reviews the employment reports as soon as they are received. If an error or
problem is found, we can notify you in time to correct the problem before the temporary
license expires.
DFS-H2-1543
69B-221.051, FAC
Revised: 7/13
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