IN THE CIRCUIT COURT FOR SHELBY COUNTY, TENNESSEE ) ) Plaintiff, Vs. ) ) ) Defendant. COST BOND as Principal(s), and . as Surety are held and firmly bound unto the Circuit Court Clerk of Shelby County, Tennessee for the payment of $500.00 Surety costs against the principal(s). To that end, we bind ourselves, our heirs, executors and administrators. The Principal(s) is/are commencing legal proceedings in the Circuit Court for Shelby County, Tennessee. If the Principal(s) shall pay(s) $500.00 costs, which are adjudged against them, then this obligation is void. If the Principal(s) fail(s) to pay, then the surety shall undertake to pay $500.00 costs adjudged against the Principal(s) mandated at Tennessee Code Annotated § 20-12-120 et seq. PRINCIPAL(S) I/We, No. Principal Social Security # Street Address City, ST, Zip Employer Employer's Street Address City, ST, Zip Principal Social Security # Street Address City, TN, Zip Employer Employer's Street Address City, ST, Zip Surety SURETY Surety Surety Street Address Signature City, ST, Zip American LegalNet, Inc. www.FormsWorkFlow.com