Fillable PROFESSIONAL BAIL BOND AGENT FINANCIAL STATEMENT (Florida Department of Financial Services)

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PROFESSIONAL BAIL BOND AGENT FINANCIAL STATEMENT (Florida Department of Financial Services)

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DFS-H2-504 Rule 69B-211.002, F.A.C.
Revised 08/07
DEPARTMENT OF FINANCIAL SERVICES ___
Division of Insurance Agent & Agency Services - Bureau of Licensing
200 East Gaines Street, Larson Building Room 419
Tallahassee, FL 32399-0319
PROFESSIONAL BAIL BOND AGENT FINANCIAL STATEMENT
ASSETS
1.
Cash on hand and in banks……………………………………………………………………….
$
2.
Notes and accounts receivable – considered good and collectible……………………………….
3.
Notes and accounts receivable – considered doubtful and included at estimate value…………..
4.
Bond, stock and other securities owned at current market or estimated actual value (schedule)..
5.
Mortgages owned considered good and collectible………………………………………………
6.
Mortgages owned considered doubtful and included at estimated value…………………………
7.
Cash surrender value of life insurance (schedule)………………………………………………..
8.
Other assets:
9. Total Assets………………………………………………………………………………………. $
LIABILITIES
1.
Accounts payable…………………………………………………………………………………..
$
2.
Notes payable to banks and others including relative (schedule)………………………………….
3.
Chattel mortgages payable…………………………………………………………………………
4.
Real estate mortgages payable……………………………………………………………………..
5.
Interest and taxes due and unpaid………………………………………………………………….
6.
Loans payable on life insurance……………………………………………………………………
7.
Outstanding judgments…………………………………………………………………………….
8.
Assets pledged as surety……………………………………………………………………………
9.
Other debts and liabilities (list)
10. Total Liabilities……………………………………………………………………………………. $
BONDS, STOCKS AND OTHER SECURITIES OWNED
1. Name and location of corporation:
2. Nature of business:
3. Description of security:
4. Par value of number of shares…………………………………………………………………….. $
5. Market or estimated value…………………………………………………………………………. $
DFS-H2-504 Rule 69B-211.002, F.A.C.
Revised 08/07
REAL ESTATE OWNED
1.
Brief description of property (nature
Assessed
Fair
Mortgages
location and improvements including
Value
Market Value
and liens
Equity
number of acres, if farm land.)
$ $ $ $
2. Title to real estate listed above is recorded in bondsman’s name, except as follows:
3. Taxes on real estate listed above has been paid in full to:
4. Interest on mortgages and other liens payable has been paid in full to:
To Whom Payable
NOTES PAYABLE
Amount
$
Date Due
/ /
$
/ /
$
/ /
PLEDGED ASSETS
Assets included above which have been pledged or hypothecated and the specific notes, mortgages, or other deeds secured by these
assets.
Description of liability secured
Description of assets pledged Value
$
and to whom payable
Amount
$
$
$
$
$
DFS-H2-504 Rule 69B-211.002, F.A.C.
Revised 08/07
OCCUPATIONAL INFORMATION
1. Present occupation or profession:
2. Name of firm, company, or employer:
3. Position occupied and nature of duties:
4. Number of years in present capacity:
5. List of firms, companies, corporations, and
organizations of which I am presently a
director, officer, employee, or partner:
6. Name and location of each financial
Institution in which any assets are held:
7. List “other assets” as itemized in item 8
of Assets section and give location of
each of them:
I hereby certify that the foregoing information and statement of financial condition is true and correct to the best of my knowledge and
belief, and that I am submitting this statement, as of , 20 , as requested by the Chief Financial Officer of the State of
Florida.
Print Name
License Number
City State Zip Code
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PROFESSIONAL BAIL BOND AGENT FINANCIAL STATEMENT (Florida Department of Financial Services)

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Completed 20 November 2020

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