Monday, March 07, 2011 Page 2 of 2
TOM GREEN COUNTY RECEIPT FOR NOTICE OF ASSIGNMENT FOR INSURANCE
COMPANIES
Please print the information below.
AGENT & BAIL BOND COMPANY NAME
LICENSE NUMBER
Receipt (by the bank cited above) is hereby acknowledged to the Treasurer of TOM GREEN County, Texas, of
written notice of the assignment to said Treasurer of the certificate of deposit / time deposit number cited. The
bank has noted in our records the importance of the certificate of deposit / time deposit as shown by
this assignment and shall not release the same without the approval of the Treasurer. We certify that we
have received no notice of any lien, encumbrance, hold, claim or obligation of the referenced certificate of
deposit / time deposit prior to the assignment to the Treasurer of TOM GREEN County. We agree to make
payment by mail upon request by the Treasurer of TOM GREEN County, Texas to the Treasurer, pursuant to
the Texas Occupations Code Chapter 1704. We agree that this certificate of deposit / time deposit and the
renewals thereof are excluded from any claim of set off or other claim arising from any debt owed to the Bank
by the Assignor. This lien on the certificate of deposit / time deposit is valid until released in writing by the TOM
GREEN County Bail Bond Board. The certificate of deposit / time deposit becomes the property of the TOM
GREEN County Treasurer if not renewed. The Bank will not alter the original structure of the certificate of
deposit / time deposit nor add an addendum to the deposit agreement without the written consent of the TOM
GREEN County Bail Bond Board.
The Bank agrees that any litigation involving this certificate of deposit / time deposit will be governed by the
laws of the State of Texas and will have as venue TOM GREEN County, Texas.
Assignor agrees not to encumber this certificate of deposit / time deposit in any way. Assignor hereby
notifies the above-named bank of the assignment.
This document must be accompanied by a letter of acknowledgement, printed on bank
letterhead, of its intent to hold this surety for __________________________________________
(insurance company name) doing business in TOM GREEN County, Texas.
NAME AND TITLE OF BANK OFFICER
OF BANK OFFICER
NAME AND TITLE OF WITNESS
OF WITNESS
Sworn to and subscribed before me this the ________ day of ______________________, A.D. 20_________.
Affix Notary Seal
Notary Public in and for the County of____________________
and the State of ____________________________________
My Commission Expires:______________________________