OFFICE OF DIANNE WILSON FORT BEND COUNTY CLERK 301 JACKSON STREET, RICHMOND, TX 77469-3108 (281) 341-8685 APPLICATION FOR REFUND OF CASH BOND CAUSE NO. STATE OF TEXAS VS Phone number: Name of person refund payable to: Residence address: Mailing address, if different: Sheriff’s receipt No. Copy of the receipt must be attached hereto. of this cash bond will be applied towards the Fine, Court Costs and $2.00 Transaction Fee in this I hereby acknowledge $ cause; and, pursuant to 117.055 Local Government Code, 5% per withdrawal of the cash bail bond, not to exceed $50.00 per withdrawal, will be retained as an Administrative Fee. If the person cannot return and does not want their refund mailed, he/she must name a person to receive payment. Name of person to receive check: Residence address: SIGNATURE: known BEFORE ME, the undersigned authority, on this day personally appeared (enter form of identification), verified to be the person whose name is to me through subscribed to the foregoing instrument and acknowledged to me that he/she executed the same for the purpose and consideration therein expressed. GIVEN under my hand and seal of office this day of , 20 . Notary Public or Deputy County Clerk County, Texas FOR OFFICE USE ONLY County Clerk date of deposit Identification of person receiving check: Total Cash Bond $ Applied to: 5% Administrative Fee Fine and Court Costs Defendant/Surety Other COMMENTS: PROCESSED BY: Check # $ Check # $ Check # $ $__________ Check # __________ I:\Misdemeanor\Forms\Refund Bond.doc American LegalNet, Inc. www.FormsWorkFlow.com