S-0135MIC MTAW Indem App (04/21) White – Producer Copy • Yellow – Indemnitor Copy Page 1 of 4
Surety:
MTAW INSURANCE COMPANY
157 MAIN STREET, GREENVILLE, PA 16125
P.O. BOX 806, GREENVILLE, PA 16125
(800) 245-0366 | FAX (724) 588-8801
Email: CourtNotices@cns.com
BAIL PRODUCER: [stamp must include name, address, phone no. and license no.]
INDEMNITOR APPLICATION AND AGREEMENT
You, the undersigned indemnitor (“Indemnitor” or “you”), hereby represent and warrant that the following declaraons made and answers given
are true, complete and correct and are made for the purpose of inducing MTAW Insurance Company (“Surety”) to issue, or cause to be issued, a
bail bond or undertaking for _______________________________________________________ ( “ D e f e n d a n t ” ) , u s i n g p o w e r o f a o r n e y n u m b e r ( s )
(if known), _________________________________________ in the total amount of _______________ Dollars ($ ) in the Court of
____________________(“Bond”).
1. INDEMNITOR NAME AND ADDRESS: RELATIONSHIP TO DEFENDANT: ________________________________
Indemnitor’s full name: ____________________________________________________ Nickname/Alias: __________________________________
Home Phone # ____________________________ Cell Phone #____________________________ Work Phone #____________________________
Email ________________________________ Social Media Username:________________________________________________________________
Current Home Address:____________________________________________________________ How Long? _______________________________
q
Rent or
q
Own? Landlord/Mortgage Company:________________________________________________________________________
Former Home Address:____________________________________________________________ How Long?________________________________
q
Rent or
q
Own? Landlord/Mortgage Company:________________________________________________________________________
2. PERSONAL DESCRIPTION: Date of Birth: ____________ Where Born: _____________________ Sex:
q
M
q
F Race ___________________
Social Security # ____________________________ Driver’s License #______________________________ Issuing State: _______________________
How Long in U.S.? ___________________ U.S. Cizen?
q
Y
q
N Naonality ____________________ Alien # ________________________
Union? _____________________________________________________ Local #_______________________________________________________
Military Service: Branch ____________________________ Acve?
q
Y
q
N Discharge Date _________________________________________
Addional Notes: __________________________________________________________________________________________________________
3. EMPLOYMENT:
Occupaon ____________________________ Employer __________________________________ Work Phone: ____________________________
How Long?________________ Employer Address ________________________________ Supervisor’s Name:_______________________________
4. MARITAL STATUS:
q
Married
q
Divorced
q
Separated
q
Widowed
q
Single
q
Cohab
Spouse/girl/boyfriend’s Name __________________________________________ How Long Married/Together? ____________________________
Address (if dierent) _______________________________________________________________________________________________________
Email ____________________________ Social Media Username:____________________________ Social Security #_________________________
Home Phone # (if dierent)______________________________________ Cell Phone # _________________________________________________
Occupaon _________________________ Employer __________________________ How Long? _________ Employer Phone # __________________
5. AUTOMOBILE: Year ______ Make _____________ Model ___________________ Color _____________ Plate # _____________ State _______
Where Financed? _____________________________________________________ Amount Owed? $ ______________________________________