VOLUNTARY ASSIGNMENT OF CASH BAIL TO OTHER FINANCIAL OBLIGATIONS TO COURT Trial Court of Massachusetts DOCKET NO(s). DEFENDANT’S NAME District Court Department AMOUNT OF CASH BAIL TO BE APPLIED TO OTHER OBLIGATIONS TO COURT FINANCIAL OBLIGATIONS TO COURT TO WHICH CASH BAIL IS TO BE APPLIED ............................................................................................................................................... SURETY’S NAME (if any) .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. DEFENDANT’S OR SURETY’S VOLUNTARY CONSENT TO ASSIGNMENT OF CASH BAIL I, the undersigned defendant or surety, have been informed that the court has authorized the return of the cash bail which I have posted in the case(s) listed above. I hereby agree that the court may deduct from such cash bail the amount listed above and apply it toward the financial obligation(s) to the court listed above. This decision is voluntary. I understand that I am not required to give such consent, and that on request I would be entitled to have returned to me the full amount of the cash bail which I have posted. SIGNATURE OF INTERPRETER I have translated this document for the defendant or surety. DATE SIGNATURE OF DEFENDANT X X COURT EMPLOYEE WITNESSING DEFENDANT’S OR SURETY’S SIGNATURE OR SIGNATURE OF SURETY X X If the defendant or surety does not sign this form in the presence of a court employee, it must also be notarized below by a notary public. COMMONWEALTH OF MASSACHUSETTS On this date the above-named defendant or surety personally appeared before me, identified himself or herself, and signed this assignment in my presence. X [SEAL] _______________________________________________________________ NOTARY PUBLIC My commission expires on: ____________________________________ (7/09) American LegalNet, Inc. www.FormsWorkFlow.com