Original - Court 3rd copy - Arresting agency Approved, SCAO 1st copy - Respondent 4th copy - Depositor STATE OF MICHIGAN CASE NO. JUDICIAL CIRCUIT CASH BOND JUDICIAL DISTRICT COUNTY Court address Court telephone no.Plaintiff Defendant v Date of arrest Arresting agency and address Agency file no. RECEIPT Received from (referred to in this receipt as "the depositor") $ to assure appearance of (referred to in this receipt as "the respondent") for contempt of court. The respondent shall appear for hearing at a date no ticed by the court. If the respondent fails to appear at the time and place indicated in the courts notice and submit to the jurisdiction of the court and fails to abide by an order of the court, the cash bond deposited sha ll be disposed according to the order of the court. If the warrant that resulted in this arrest arises from a case in which the re spondent has an unpaid judgment, the cash bond may be transmitted to the creditor holding the judgment. By depositing the cash bond with the officer and accepting this receipt, the depositor waives a claim to the money under the cash b ond following its disposition as ordered by the court. Date Signature of depositor of money Officer Department Department receipt number TERMS AND CONDITIONS To secure my release from custody until the court hearing, I promise: 1. I will personally appear at the time and place as directed by the court. 2. I will immediately notify the court in writing of any change in my addre ss or telephone number. I understand that at the hearing the court will determine how much of th e bond money will be applied to any outstanding judgment in this case and how much, if any, will be returned to the depositor. I understand that if I fail to appear, the court will issue a bench warr ant for my arrest and the bond money posted may be forfeited or applied to any outstanding judgment in this case. Signature of respondent Date Address of respondent Employer City, state, zip Employers address Date of birth City, state, zip Driver license no. MC 92 (6/05) CASH BOND MCR 3.604, MCL 600.1701 American LegalNet, Inc. www.USCourtForms.com