"Professional Bail Bond Agent Financial Statement" - Mississippi

Professional Bail Bond Agent Financial Statement is a legal document that was released by the Mississippi Department of Insurance - a government authority operating within Mississippi.

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MIKE CHANEY
MISSISSIPPI INSURANCE DEPARTMENT
Commissioner of Insurance
LICENSING DIVISION
State Fire Marshal
P.O. BOX 79
MARK HAIRE
Deputy Commissioner of Insurance
JACKSON, MS 39205-0079
PROFESSIONAL BAIL BOND AGENT FINANCIAL STATEMENT
Name of Professional Bail Agent
License No.
Business Trade Name
Physical Address
(Street and Number)
City or Town
State
Zip Code
Mailing Address
(Street and Number)
City or Town
State
Zip Code
County
Telephone
Email Address
STATE OF MISSISSIPPI
County of ___________________
I hereby certify that the foregoing information and state of financial condition is true and correct to the
best of my knowledge and belief.
________________________________________
Professional Bail Bond Agent (signature required)
Sworn to and subscribed before me, the undersigned authority in and for the State and Count this day of
____________________, 20_____.
My commission expires___________________
________________________________
Notary Public
Page 1 of 3
MIKE CHANEY
MISSISSIPPI INSURANCE DEPARTMENT
Commissioner of Insurance
LICENSING DIVISION
State Fire Marshal
P.O. BOX 79
MARK HAIRE
Deputy Commissioner of Insurance
JACKSON, MS 39205-0079
PROFESSIONAL BAIL BOND AGENT FINANCIAL STATEMENT
Name of Professional Bail Agent
License No.
Business Trade Name
Physical Address
(Street and Number)
City or Town
State
Zip Code
Mailing Address
(Street and Number)
City or Town
State
Zip Code
County
Telephone
Email Address
STATE OF MISSISSIPPI
County of ___________________
I hereby certify that the foregoing information and state of financial condition is true and correct to the
best of my knowledge and belief.
________________________________________
Professional Bail Bond Agent (signature required)
Sworn to and subscribed before me, the undersigned authority in and for the State and Count this day of
____________________, 20_____.
My commission expires___________________
________________________________
Notary Public
Page 1 of 3
Professional Bail Bond Agent Financial Statement
Year Ending December 31, 2017
Assets
Amount in Dollars
Cash - checking accounts…………………………………………………….
Cash - savings accounts……………………………………………………...
Certificates of deposit…………………………………………………………
Securities - stocks / bonds / mutual funds………………………………….
Notes & contracts receivable…………………………………………………
Life insurance (cash surrender value)………………………………………
Personal property (autos, jewelry, etc.)…………………………………….
Retirement Funds (eg. IRAs, 401k)………………………………………….
Real estate (market value)……………………………………………………
Other assets (specify below)…………………………………………………
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
Total Assets…………………………………………………………………..
Liabilities
Amount in Dollars
Accounts Payable……………………………………………………………..
Notes payable………………………………………………………………….
Taxes payable…………………………………………………………………
Real estate mortgages ……………………………………………………….
Other liabilities (specify below)………………………………………………
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
Total Liabilities……………………………………………………………….
Net Worth………………………………………………………..
(Supplemental Financial Information can be provided on Page 3 if needed)
My total pending liabilities as endorser, professional bail bond agent as of 12/31/20_____.
$__________________________.00
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Are any judgements or lawsuits pending against you?
YES
NO (If “YES” Explain Below)
Provide any supplemental financial information in the space below.
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