VOLUNTARY ASSIGNMENT OF CASH BAIL
TO OTHER FINANCIAL OBLIGATIONS TO COURT

DOCKET NO(s).

Trial Court of Massachusetts
District Court Department

DEFENDANT’S NAME

AMOUNT OF CASH BAIL TO BE APPLIED TO OTHER OBLIGATIONS TO COURT

SURETY’S NAME  (if any)

FINANCIAL OBLIGATIONS TO COURT TO WHICH CASH BAIL IS TO BE APPLIED

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DEFENDANT’S OR SURETY’S VOLUNTARY CONSENT TO ASSIGNMENT OF CASH BAIL

I, the undersigned defendant or surety, have been informed that the court has authorized the return

of the cash bail which I have posted in the case(s) listed above.

I hereby agree that the court may deduct from such cash bail the amount listed above and apply it

toward the financial obligation(s) to the court listed above.  This decision is voluntary.  I understand

that I am not required to give such consent, and that on request I would be entitled to have returned

to me the full amount of the cash bail which I have posted.

SIGNATURE OF INTERPRETER
I have translated this document for the defendant or surety.

DATE

SIGNATURE OF DEFENDANT

COURT EMPLOYEE WITNESSING DEFENDANT’S OR SURETY’S SIGNATURE

OR

SIGNATURE OF SURETY

  X

  X

If the defendant or surety does not sign this form in the presence of a court employee, it must also be notarized below by a notary public.

COMMONWEALTH OF MASSACHUSETTS

On this date the above-named defendant or surety personally appeared before me, identified himself or herself, and signed this assignment
in my presence.

X  _______________________________________________________________

NOTARY PUBLIC

My commission expires on: ____________________________________

  X

  X

[SEAL]

(7/09)