State of California--Health and Human Services Agency California Department of Public Health Licensing and Certification Program SURETY BOND VERIFICATION Reply to: California Department of Public Health Licensing and Certification Program Centralized Applications Unit P.O. Box 997377, MS 3402 Sacramento, CA 95899-7377 California Health and Safety Code, Section 1318, Chapter 2, Division 2, requires that licensed health facilities that handle money in excess of $25 per patient or over $500 for all patients in any month, be bonded for not less than $1,000. This is to serve as a guarantee for the faithful and honest handling of the money of such patients. INSTRUCTIONS: This form is to be completed by the bonding agency. In addition, attach an original copy of the bond. In the event of cancellation of the bond, please send notice to the above licensing office. BE IT KNOWN THAT: Facility name Facility address State of California, as Principal, and Bonding agency Agency address State of City County ZIP code City County ZIP code , as Surety, are held and firmly bound unto the STATE OF CALIFORNIA in the full and just sum of DOLLARS ($ ), for the payment of which the said Principal and said Surety bind themselves, their respective heirs, successors, and assigns, jointly and severally, firmly by these presents. The CONDITION of this obligation is such that WHEREAS, the Principal has applied for or has been issued a license by the California Department of Public Health to maintain or conduct a health facility pursuant to Chapter 2, Division 2, of the Health and Safety Code of the State of California; and WHEREAS, by the terms of Section 1318 of said code, the Principal is required to file with the California Department of Public Health, Licensing and Certification, the bond running to the State of California. NOW, THEREFORE, if the above bounden Principal shall faithfully and honestly handle money of patients in the care of said Principal, then this obligation shall be null and void; otherwise to remain in full force and effect. Every patient injured as a result of any improper or unlawful handling of the money of a patient of a health facility may bring an action in a proper court on the bond required to be posted by the licensee pursuant to this section for the amount of damage he/she suffered as a result thereof to the extent covered by the bond. This bond may be canceled by the Surety in accordance with the provisions of Section 996.310 et seq. of the Code of Civil Procedure. This bond is effective and continuous. Date IN WITNESS WHEREOF, we have subscribed our names and impressed our seal this Day , Month , Year . Bonding agent name (please print) Bonding agent signature BONDING AGENCY SEAL HS 402 (2/08) American LegalNet, Inc. www.FormsWorkflow.com