Cox Bail Bond, Inc

Cox Bail Bond, Inc. Credit Card Information

Type of Credit Card: Mastercard: Visa: Discover: Premium: Cash Collateral: Both: Defendant: Credit Card Number: Cardholder Name: Cardholder Address: Street City State Zip Card Expiration Date: Amount of Premium: Add 5% for Credit Card Fee Amount of Collateral: Add 5% for Credit Card Fee Authorization #:

PREMIUM & CASH COLLATERAL ARE DONE AS TWO SEPARATE TRANSACTIONS: ------

I further agree that in the event the initial premium is not paid within 90 days, this credit card may be processed for any outstanding premium. In addition, if this bond is forfeited I authorize Cox Bail Bonds to process this card for a fugitive recovery fee of no less than 10% of the face amount of the original bond plus any recovery expenses.

Cardholder: ______Signature Date

Defendant: ______Signature Date

Mastercard and Visa: 1-800-228-1122 Discover: 1-800-347-1111 Merchant Number: 4228991500002389 Bank Number: 062100 Location ID Number: V6376302