Statement of Surrender Form
This form must be completed at the time of the surrender of a defendant by a bail bond agent with a copy provided to the defendant,
pursuant to §648.4425, Florida Statutes. If a jail has a separate surrender form; this form must be completed and attached to that form.
Defendant’s full name:
Criminal court case number: Surrender Date:
Reason for surrender:
Please check one of the following:
Bail bond agent physically surrendered defendant
Defendant already in custody on other charges
? Yes No (If no, explain below)
Was a surrender fee charged?
Yes No
If yes, state the amount and reason for the fee:
I DO HEREBY CERTIFY THAT I AM A LICENSED AND APPOINTED BAIL BOND AGENT PURSUANT TO CHAPTER 648,
FLORIDA STATUTES. I FURTHER CERTIFY THE SURRENDER OF THE ABOVE LISTED DEFENDANT IS FOR THE REASON
STATED ABOVE
. I UNDERSTAND THAT WHOEVER KNOWINGLY MAKES A FALSE STATEMENT IN WRITING WITH THE
INTENT TO MISLEAD A PUBLIC SERVANT IN THE PERFORMANCE OF HIS OR HER OFFICIAL DUTIES IS GUILTY OF A
MISDEMEANOR OF THE SECOND DEGREE
, PURSUANT TO §837.06, FLORIDA STATUTES.
Bail Bond Agent Signature:
Bail Bond Agent Printed Name:
Bail Bond Agent License Number:
Bail Bond Agency Address:
Signature of Receiving Officer (if applicable)
Original: Attach to jail surrender form (if applicable)
Copy: Defendant
Copy: Bail bond agent’s file
DFS-H2-1542 69B-221.100 (2), F.A.C.
Revised 06/11
