AFTAB PUREVAL CLERK OF COURTS, HAMILTON COUNTY, OHIO LOST BOND RECEIPT AFFIDAVIT CASE NO. RECEIPT NO. I, (YOUR NAME) , DO HEREBY CERTIFY THAT ON (DATE BOND WAS POSTED) I POSTED BOND IN THE AMOUNT OF $ FOR (DEFENDANT) AND SINCE THAT TIME I HAVE LOST MY RECEIPT FOR SAID BOND. SURETY SWORN TO BEFORE ME AND SIGNED IN MY PRESENCE THIS DAY OF , 20 , , NOTARY PUBLIC HAVE THIS LOST BOND RECEIPT AFFIDAVIT NOTARIZED PAY A $2.00 PROCESSING FEE IN THE COURTHOUSE ROOM 315, PAPER ROOM BAIL REFUND MONDAY ­ FRIDAY, 8:00 A.M. ­ 3:30 P.M. ONLY 1000 Main Street, Room 315 American LegalNet, Inc. www.FormsWorkFlow.com