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Department of Financial Services Division of Agent & (Florida Department of Financial Services)

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Department of Financial Services
Division of Agent & Agency Services – Bureau of Licensing
Individual Application for Temporary Permit to Operate a Bail Bond Agency
DFS-H2-2083 (Eff. 03/13) Page | 1
69B-221.155, F.A.C.
Today’s Date:
Applicant
First: MI: Last:
Date of Birth: Social Security #*:
*NOTE
You are required by state and federal law to disclose your social security number on this application. Section 666(a)(13) of Title
42, Unites States Code, requires each state to obtain the social security number of each applicant for a professional or
occupational license on the application for the license. Section 626.171(5), Florida Statutes, implements this federal law. The
purpose of collecting social security numbers is for administration of the child support enforcement provisions of Title IV-D of
the Social Security Act. The Department of Financial Services also uses social security numbers for identity verification purposes
in conjunction with background checks of applicants and for identity verification purposes in the Department's electronic
database for licensees and applicants.
Addresses
Street:
City: State: Zip Code:
Phone: Cell:
Email:
Agency
Name:
Street:
City: State: Zip Code:
Phone: Fax:
Primary Bail Bond Agent: License #:
Previous Agency Owner: License #:
Reason for request for permit: Death of owner Mental incapacity of owner
Relationship of applicant to owner:
Please submit documentation attached to this application to support your responses above.
Are you currently licensed by the Department of Financial Services?
Yes No
If yes, please provide your license number:
Are you a jailer, police officer, committing magistrate, sheriff, deputy sheriff,
employee of a court or clerk of any court, attorney or do you have the power to
arrest or have anything to do with the custody or control of federal, state, county or
municipal prisoners?
Yes No
Florida Department of Financial Services
Division of Agent & Agency Services – Bureau of Licensing
Individual Application for Temporary Permit to Operate a Bail Bond Agency
DFS-H2-2083 (Eff. 03/13) Page | 2
69B-221.155 F.A.C.
Are you a United States citizen or legal alien with a work permit?
Yes No
Have you ever been convicted, found guilty, or pled guilty or nolo contendere (no
contest) to a felony, or crime of moral turpitude, or a crime punishable by
imprisonment of 1 year or more under the laws of any municipality, county, state,
territory or country, whether or not adjudication was withheld or a judgment of
conviction was entered?
Yes No
Are you currently on probation for any legal action or participating in a pretrial
intervention program or any other diversion programs?
Yes No
Are there currently pending against you or any entity you control, any criminal,
administrative or civil charges in any state or federal court anywhere in the United
States or its possessions or any other country?
Yes No
Has a judgment ever been obtained or is there currently pending any type of civil
action as it relates to insurance against you individually or against any entity in which
you are or were an officer, director, partner, or owner?
Yes No
Has any company ever refused to bond you?
Yes No
Have you ever been refused a securities, real estate broker or other license by a
state agency or public authority in any jurisdiction?
Yes No
Have you ever had an application for a license declined or denied by this or any
other insurance regulatory body?
Yes No
Have you ever had any professional license subject to any of the following:
Revoked in Florida or any other state?
Yes No
Suspended in Florida or any other state?
Yes No
Placed on probation?
Yes No
Administratively fined or a penalty imposed?
Yes No
Had a cease and desist order issued against it?
Yes No
Have you ever had any agent or producer contract terminated by an insurance
company or managing general agent for any alleged cause?
Yes No
Do you have a child support obligation in arrearage?
Yes No
Do you understand that this permit, if issued, is valid for no more than 24 months?
Yes No
Do you understand that this permit, if issued, does not authorize you to engage in
any activities as a bail bond agent or as a temporary bail bond agent?
Yes No
Do you affirm that you will maintain a properly licensed and appointed bail bond
agent as the designated primary bail bond agent for this agency?
Yes No
Do you understand that you must advise the department of any change in your
home address, mailing address, and email address or phone numbers?
Yes No
Florida Department of Financial Services
Division of Agent & Agency Services – Bureau of Licensing
Individual Application for Temporary Permit to Operate a Bail Bond Agency
DFS-H2-2083 (Eff. 03/13) Page | 3
69B-221.155 F.A.C.
Do you understand that you must advise the department of any change in the
agency’s business address, mailing address, and email address or phone numbers?
Yes No
I have attached sworn statements by at least three (3) reputable citizens who are
residents of the same county where this bail bond agency is located, attesting to my
integrity and moral character.
Yes No
I understand I must have my fingerprints taken by LiveScan method at one of the
Department’s fingerprint sites before my application will be considered for approval.
Yes No
I understand this permit does not allow me to execute or sign bonds, handle
collateral receipts, deliver bonds to appropriate authorities, present defendants in
court, apprehend or arrest defendants, or surrender defendants to the appropriate
authorities.
Yes No
I understand this permit will allow me to operate and receive income for this bail
bond agency for a maximum of 24 months without obtaining a license as a limited
surety (bail bond) agent in Florida.
Yes No
I have attached an original certified copy of the death certificate or certificate of
mental incapacitation of the owner of this agency.
Yes No
Florida Department of Financial Services
Division of Agent & Agency Services – Bureau of Licensing
Individual Application for Temporary Permit to Operate a Bail Bond Agency
DFS-H2-2083 (Eff. 03/13) Page | 4
69B-221.155 F.A.C.
Applicant Affirmation Statement
Where required by law, I hereby name and appoint the Chief Financial Officer of the State of Florida my
attorney to receive service of legal process issued against me, upon causes of action arising within the
State of Florida out of transactions under my Florida license; that this appointment shall constitute
effective legal service upon me as long as there may be any cause of action against me arising out of
insurance transactions within the State of Florida. (Sections 626.741; 626.742; 626.792; 626.835;
626.836; 626.84201, F.S.)
Whoever knowingly makes a false statement in writing with the intent to mislead a public servant in the
performance of his/her official duty shall be guilty of a misdemeanor of the second degree provided
under section 837.06, F.S.
Under penalties of perjury, I declare I have read the foregoing application and that the facts stated in it
are true to the best of my knowledge and belief; and that I have not withheld any information that
would in any way affect my qualifications. I understand that misrepresentation of any fact required to
be disclosed through this application is a violation of the Florida Insurance Code and may result in the
denial of my application and/or the revocation of my insurance license(s).
I understand that as an applicant who is subject to a national fingerprint-based criminal history record
check, I have certain rights based on Title 28, Code of Federal Regulations (CFR), Section 16.30 – 16.34.
The rights include a reasonable time to respond to the agency for any deficiencies reported in the
criminal history report; the ability to challenge the accuracy of the information in the report by
contacting the FBI; and any records held by the agency will be used and retained according to the FBI’s
Criminal Justice Information Services (CJIS) requirements. A copy of the a Noncriminal Justice Applicants
Privacy Rights may be obtained by visiting the agency’s website at
https://www.myfloridacfo.com/Division/Agents/ .
I understand that, per section 626.171(5), F.S., all application fees are non-
refundable.
Signature of Applicant
Date
Send this form and any attachments to:
Florida Department of Financial Services
Division of Agent & Agency Services
Bureau of Licensing
200 East Gaines Street, Room 419
Tallahassee FL 32399-0319
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Completed 20 November 2020

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