United States District Court

Northern District of Illinois

____________Division

TO SECURE A BOND

Defendant’s Name:____________________

Case No:__________

I, (Name of person depositing cash) state that I am the person making the cash deposit of (Amount of cash) to secure the bond of defendant (Name of the defendant whose bond is secured by this deposit).

I directed the Clerk of the Court to refund this cash deposit as follows (Initial one or both and indicate the amount(s) to be refunded):

$(Amount) to me (Initials)

$(Amount) to (Name of person to receive refund) (Initials) of

(Street address)

(City, State and ZIP code)

(Signature of depositor)

Date:__________ (Street address of depositor)

Receipt No._______ (City, State and ZIP code of depositor)

INSTRUCTIONS

1. The person depositing cash with the clerk to secure the release of a defendant in a criminal case shall complete the form on the reverse. (The cashier will provide the receipt number.)
2. Refunds of cash deposits are governed by LCrR46.1(c).
3. The clerk will refund monies deposited without additional order of court only to the person or persons indicated on the reverse of this document.
4. In order to make the payment without specific order of court the clerk requires that this document, the original receipt, and the assignment, if any, be surrendered to the cashier at the time the request for refund was made.