DEFENDANT BAIL BOND APPLICATION AND AGREEMENT
You, the undersigned Defendant (“Defendant” or “you”), hereby represent and warrant that the following declaraons 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 you,
using power of aorney number(s) (if known) ________________________________________________________________________________________, in the
total amount of _______________________________________Dollars ($______________________) in the __________________________________Court of
_______________________ (“Bond”).
DEFENDANT’S NAME AND ADDRESS
1. Name________________________________________________________________________ Nickname/Alias ________________________________________
First Middle Last
2. Home Phone # _______________________________ Cell Phone # ____________________________ Work Phone # _____________________________________
3. Email _________________________________ Social Media Accounts __________________________________________________________________________
4. Current Home Address ________________________________________________________________________________________________________________
5. How Long? ____________ Rent or Own? ___________ Landlord ______________________________________________________________________________
6. Former Home Address _________________________________________________________________________________________________________________
7. How Long? ________ Rent or Own? ___________ Landlord ___________________________________________________________________________________
8. How long resided in current city? _______________ How long in current state? ______________________ How Long in U.S.? _____________________________
PERSONAL DESCRIPTION
9. Date of Birth _____________________ Where Born (City & State) ________________________________________ Sex ___________ Race __________________
10. Social Security # _________________________________ Driver’s License # ______________________________ Issuing State _____________________________
11. Passport Issuing Country(s) _______________________________________ Passport ID (s) _________________________________________________________
12. Height _____________ Weight__________ Eye Color ______________ Hair Color _____________
13. Scars, Marks, Taoos __________________________________________________________________________________________________________________
14. U.S. Cizen? Yes No Naonality _________________________________________________ Alien # _________________________________
15. Any Medical Condions/Disabilies_______________________________________________________________________________________________________
16. Union? _______________________ Local # _____________________ Military Service: Branch _________________ Acve? ________ Discharge Date __________
EMPLOYMENT
17. All Occupaons for the past 5 years: _______________________________________________________________________________________________________
18. Current Employer _____________________________________________________________________________________________________________________
19. Name ______________________________________ How Long? __________________ Posion _____________________________________________________
20. Supervisor’s Name __________________________________________________ Phone #______________________________
21. Most Recent Former Employer: __________________________________________________________________________________________________________
22. Name _________________________________ How Long? __________________ Posion _________________________________________________________
23. Supervisor’s Name __________________________________________________ Phone #______________________________
24. Supervisor’s Name __________________________________________________ Phone #______________________________
MARITAL STATUS/CHILDREN: Married Divorced Separated Widowed Single Cohab
25. Spouse/girl/boyfriend’s Name ______________________________________________________________ How Long Married/together? _____________________
First Middle Last
26. Address (if dierent) ___________________________________________________________________ Email___________________________________________
27. Home Phone # (if dierent) _________________________ Cell Phone # _____________________________ Social Security # _____________________________
28. Occupaon _______________________________________ Employer ______________________________________________ How Long? __________________
29. Supervisor’s Name ________________________________ Work Phone #___________________________________________
30. Child’s Name Date of Birth School/Employer Other Parent’s Name
__________________________________ _________________ _____________________________ __________________________________________
__________________________________ _________________ _____________________________ __________________________________________
S-0136MIC MTAW DEFT APP (04/21) White – Producer Copy • Yellow – Defendant Copy Page 1 of 3
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@cns.com
BAIL PRODUCER: [stamp must include name, address, phone no. and license no.]