Fillable Printable Sworn Statement Form - Florida

Sworn Statement Form - Florida

DEPARTMENT OF FINANCIAL SERVICES

Division of Agent & Agency Services - Bureau of Licensing

200 E Gaines Street, Larson Building

Tallahassee FL 32399-0319

DFS-H2-1500 69B-221.155, F.A.C.

(06/11)

Limited Surety Agent, Professional Bail Bond Agent

Sworn Statement

Florida Statutes §648.34(1), states: “An application for licensure as a bail bond agent must be

submitted on forms prescribed by the department…” and §648.34(2)(d) requires that “The

applicant is vouched for and recommended upon sworn statements filed with the department by at

least three reputable citizens who are citizens of the same counties in which the applicant proposes

to engage in the bail bond business.”

The applicant being vouched for on this form:

First name

Middle

Last Name

Social Security #

I, the undersigned, hereby certify that the individual listed above, who has filed an application for

license-examination required as a limited surety (bail bond) agent is personally known to me and is

of good business reputation and of good moral character.

I also attest that I am a resident of a county where this applicant proposes to engage in the bail

bond business.

Signature

County of residence

Printed Name

Street Address

Phone Number

City, State Zip Code

A TOTAL OF AT LEAST THREE (3) FORMS SHOULD BE SUBMITTED WITH YOUR APPLICATION FOR LICENSE

Note:

You are required by federal law to disclose your social security number on this form which is a part of your

application for licensure. Section 666(a)(13) of Title 42, United 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. 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.