( RCr 4.34 )

(Caption)

The affiant says that he resides in __________________ County, __________________, (State) and owns in his own right the following property:

Location

Description (County and state) Value

1. $

2. $

There are no encumbrances against except as follows:

Name and address of lienholder or claimant Amount of lien or claim

1. $

2. $

The affiant is not obligated on any other bonds or undertakings for bail except as follows:

Name of principal Court in which taken Amount

1. $

2. $

__________________

(Surety)

Subscribed and sworn to before me at ______, this ______ day of ______, 19______.

__________________

(Signature)

__________________

(Title)