AFTAB PUREVAL HAMILTON COUNTY CLERK OF COURTS AUTHORIZATION BY SURETY TO RELEASE CRIMINAL BAIL BOND REFUND TO A THIRD PARTY 1. , hereby authorize the Hamilton County I, [insert printed name] Clerk of Courts (the "Clerk") to release to the individual described below the bond refund due to me in Case . No(s). I understand that the refund check will still be issued in my name although the refund check itself will be given to the person described below. I have attached to this authorization the original receipt copy for the bond being refunded or, in the case of a lost or missing bond receipt, I have attached to this authorization the required "Lost Bond Receipt Affidavit" in order to have a duplicate receipt generated. As proof of my intentional authorization I have had this authorization form witnessed and notarized and have attached a photocopy of my current Driver's License or State of Ohio Identification Card, as applicable. The person to whom this bond refund check should be issued is described below and he or she shall provide a valid Driver's License or State of Ohio Identification Card (or other appropriate photo I.D.) as proof of his or her identity: Name: _________________________________________________________________ Address: _______________________________________________________________ Home Telephone: ________________________________________________________ Social Security No.: _____________________________________________________________ Driver's License No.: ____________________________________________________________ Date of Birth: ________________ Gender: M or F Race: ______________________ 6. In Witness Whereof, I have hereunto subscribed my name. Signed: __________________________________ ("Surety") Print Name: ___________________________________ Dated: _______________________________________ Sworn to and subscribed in my presence at on the Signed: Notary Public/Witness [SEAL] 2. 3. 4. 5. day of , 20 . My Commission Expires: HCCOC STAFF: · Be sure that there is a bond refund due and payable. · Be sure original receipt or lost receipt affidavit attached. · Be sure that Surety's photo identification copy is attached. · Be sure that this form is notarized. · Be sure that person picking up bond refund check has photo I.D. and that a copy of it is made and attached to this paperwork. Insert here: Refund Amount: $ Bond Refund Auth Form - Revised 01/03/17 Refund Check No.: American LegalNet, Inc. www.FormsWorkFlow.com