Upon the failure to appear or upon any violation of any terms and conditions required by the Court and surety of as required by the Court of Common Pleas in County, I/we promise to pay to the order of Bail USA, Inc.

$20On demand after date we promise to pay to the order of Bail USA, Inc,$


Dollars Payable at 157 Main Street, P. O. Box 806, Greenville, PA 16125 without defalcation, value received with interest at the legal rate.

AND FURTHER, I/we do hereby empower any Attorney of any Court of Record within the United States or

elsewhere to appear for me/us and after one or more declarations filed, confess judgment against me/us as of any term for the above sum plus any and all expenses that may be incurred by Bail USA, Inc. in apprehending me/us, with costs of suit and attorney's commission of 10 percent for collection and release of all errors, and without stay of inquisition and extension upon any levy on real estate as hereby waived and condemnation agreed to and the exemption of personal property from levy and sale on any execution hereon is also hereby expressly waived, and no benefit of exemption be claimed under and by virtue of any exemption law now in force or which may be hereafter passed

WITNESS my hand and seal.

Signature


Printed Name & Mailing Address

Signature

Printed Name & Mailing Address

Signature

Printed Name & Mailing Address

Terms: Due On Demand

Revised 08/2006

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By: DGloby