IN THE CIRCUIT COURT OF COUNTY, MISSOURI Judge or Division: Case Number: State of Missouri vs. Affiant: (Name and Address) (Date File Stamp) Special Affidavit of Qualification (Surety Bond - General Affidavit Filed and Current) I, being duly sworn, depose and state that: 1. I desire to sign the bail bond of the defendant in the above entitled case and make this affidavit in order to quality as surety on such bond. 2. I am the same person who, within the last month, signed the general affidavit of qualifications and questionnaire in this court. 3. My financial condition has not changed materially in any respect since the filing of said affidavit and questionnaire, that I have not for any reason become disqualified, and that all the facts set out in the general affidavit and questionnaire and material to my qualifications as surety remain as stated in the affidavit and questionnaire. 4. I have read and personally answered each question in the following questionnaire and that my answers are true and correct, and that in addition to signing and swearing to this affidavit, I have signed my name at the end of the questionnaire as a guarantee of the truthfulness and genuineness of the answers provided. (Seal) Signature of Affiant Subscribed and sworn to before me Date Clerk/Deputy Clerk OSCA (4-95) CR170 1 of 2 Rules 33.17, 33.20 American LegalNet, Inc. www.USCourtForms.com Questionnaire 1. Have you or has any person for you directly or indirectly received any compensation or security for the signing of the bond which you now propose to sign in the case noted on this reverse side? Yes 2. No If your answer to question 1 is yes, state below the name of the person or persons paying such compensation or giving such security, together with the address of each person so named, the exact amount of any compensation paid or promised to be paid, and the exact amount and nature of any security given or promised to be given by each of said persons, and all other details as to each compensation of securityor promise of compensation or security. Date OSCA (4-95) CR170 Signature of Affiant 2 of 2 Rules 33.17, 33.20 American LegalNet, Inc. www.USCourtForms.com