Fillable Form 200 00012 (Vermont Judiciary)

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Form 200 00012 (Vermont Judiciary)

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Issued by: _____________________
200-00012 – Lost Bail Receipt Affidavit (01/2018) Page 1 of 1
www.vermontjudiciary.org
Vermont Superior Court
Docket Number:
Bail Amount: $
STATE OF VERMONT v.
LOST BAIL RECEIPT AFFIDAVIT
I _____________________________, Bailor in the above-captioned case, do hereby submit to the
, that I have lost or misplaced the original bail receipt furnished to me in
the amount of $________________ relating to Bail in the above case. After a diligent search, I have
been unable to locate the original receipt.
If I find the original Bail receipt, I will immediately forward it to the court at the above address.
Dated
_____________________________ ___________________________________
Signed
Court Use Only
Date: _____________________
Check: _____________________
Amount: $____________________
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Form 200 00012 (Vermont Judiciary)

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Completed 15 July 2020

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