ATTESTATION:
BY ENTERING MY SIGNATURE BELOW I ATTEST AND CERTIFY UNDER OATH THAT I HAVE CHARGED
THE CORRECT PREMIUM RATE FOR ALL SURETY BONDS, AND THAT I HAVE NOT CHARGED LESS
THAN, OR MORE THAN, THE FILED PREMIUM RATE AS SET BY LAW. ADDITIONALLY, OTHER THAN
THE PREMIUM RECEIVED FOR THE BOND, I HAVE NOT ACCEPTED ANYTHING OF VALUE FROM, NOR
RETURNED PREMIUM MONEY TO, CONSUMERS AS AN INDUCEMENT FOR ISSUING A SURETY BAIL
BOND.
I ALSO CERTIFY UNDER PENALTY OF PERJURY, THAT I AM THE PERSON NAMED HEREIN AND THAT
ALL INFORMATION SUBMITTED ON THIS FORM IS TRUE AND COMPLETE. I ATTEST THAT I HAVE
THE AUTHORITY AND CAPACITY TO EXECUTE THIS CERTIFICATION. I AM AWARE THAT SUBMITTING
FALSE INFORMATION OR OMITTING PERTINENT OR MATERIAL INFORMATION IN CONNECTION WITH
THIS FORM IS GROUNDS FOR ADMINISTRATIVE SANCTION INCLUDING FINES, SUSPENSION OR
REVOCATION OF MY LICENSE BY THE DEPARTMENT.
NOTE: The filing
of a false certification by a surety bail bond agent or failure to file the certification
by the tenth of each month shall be grounds for administrative action in accordance
with section 38a-774 of the general statutes. Should the tenth of the month fall
on a legal holiday or weekend, the form will be due the next business day following.
(This should be your valid e-mail address to receive the confirmation of your submission)
CT BAIL BOND LICENSE NUMBER:
(Use the last four digits of your SSN number for Individual or last four digits
of the Tax-ID for Business Entity)