48 Hour Missing Money Bond Request

Abandoned / Unclaimed Property Bond Request
Please note, you are in a secure area

Principal/Applicant Individual Corp Other

Name

Address # Street Name St./Ave.

City/State/Zip

Social Security #

Phone

Fax

Email

Tax ID (if applicable)

Your Name, or Business Name
(as it appears on bond)

Amount

To Whom Bond is Payable

Address

City/State/Zip

1. You have thoroughly investigated this property and have determined
that you have a proper and valid claim to it. Yes No

Explain:

2. You are the sole owner and no other party has an interest in this property
or any portion of this property. Yes No

Explain:

3. You agree to hold the Surety harmless in the event another party claims
an interest in this property or a portion of this property. Yes No

Explain:

A negative answer would generally cause this bond/applicant to be rejected.

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*On bonds over $50,000 please continue by filling out this Financial Statement below.
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Applicant is	Married Single Separated
If married the financial statement is:	Completed Jointly Not Completed Jointly
	Individual Co-Partnership Corporation

Statement of Assets and Liabilities as of:
Month Year

* ASSETS * LIABILITIES

Cash Due to Banks (unsecured)

Stocks, bonds, etc Credit Cards

Accounts Receivable Taxes

Notes Receivable Accounts Payable

Vehicles Notes Payable

Equipment Due on Inventory

Home Due on Real Estate

Real Estate Other Liabilities

IRA Total Liabilities

Other Assets Net Worth

TOTAL ASSETS TOTAL LIAB. and NET WORTH

* Additional information may be required to verify balances over $10,000.

SOURCES OF INCOME FOR YEAR ENDED OTHER LIABILITIES

Salary, bonuses & commissions $ Do you have any contingent liabilities? No Yes
If Yes, explain

Dividends $

Real Estate Income $

Other income 1 $ Endorser, co-maker of guarantor? $

Other income 2 $ On Leases or contracts? $

Other income 3 $ Legal Claims (Judgments, etc) $

Other income 4 $ Other special debt $

TOTAL $ Amount of contested tax liens $

Are any assets owned by a trust?
No Yes
If Yes, describe Ever declared bankrupt?
No Yes
If Yes, explain

Do you have a will?
No Yes If Yes,
Name the executor Are you a defendant in any suits or legal action?
No Yes
If Yes, explain

Are you a partner or officer in any other venture?
No Yes
If Yes, describe Are any assets pledged?
No Yes
If Yes, explain

Any other obligations, alimony, child support, etc?
No Yes
If Yes, explain Income tax paid through Year
Name your personal bank

By submitting information through this site, I authorize you and/or the surety to contact the individuals and companies given as references or other sources to gather information on the credit, character and capacity of the individuals and the company.

Name: Title: Date:

Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or application containing any false, incomplete, or misleading information is guilty of a felony per state statute.

Press the Submit button below or you can fax or email to:
fax (561) 997-7087 or email to: bonds@beacongroupinc.com. or call 1-800 545-9007 ext. 133
Richard S. Wurst, ARM, AAI - License D048332 (Office use only)