(Caption)

________________________ (Name of defendant) being in custody charged with the offense of ______ and being admitted to bail in the sum of $_____, we undertake that he will appear and be amenable to the orders and process of this and any other court in which this proceeding may be pending hereafter for any and all purposes and at all stages of the proceeding (including, in event of indictment, proceedings thereafter) in accordance with RCr 4.54.

Executed this _____ day of _____, 19_____.

__________________ __________________

(Name of defendant) (Address)

__________________ __________________

(Name of surety) (Address)

Taken and subscribed before me this _____ day of _____, 19__.

__________________

(Signature)

__________________

(Title)

I, __________________, by entering into the (above) bond obligation, do hereby submit to the jurisdiction of the courts of Kentucky in which any forfeiture proceeding arising out of my bail obligation may be pending, and do further irrevocably appoint the clerk of such court as my agent upon whom any process affecting my liability on such bond maybe served, such clerk to forthwith mail copies to me at ____________, (Street Address) City of ___________, County of ___________, State of ___________, or at my last known address.

Dated this _____ day of _____, 19_____.

__________________

(Name)