Plaintiff’s name, address, and telephone no.

Defendant’s name, address, and telephone no.

Plaintiff’s attorney, bar no., address, and telephone no.

Defendant’s attorney, bar no., address, and telephone no.

Received from 
 

 (referred to in this receipt as “the depositor”) $ 
 

to assure appearance of 
contempt of court. The respondent shall appear for hearing at a date noticed by the court.

 

 (referred to in this receipt as “the respondent”) for

If the respondent fails to appear at the time and place indicated in the court’s notice and submit to the jurisdiction of the
court and fails to abide by an order of the court, the cash bond deposited shall be disposed according to the order of the
court. If the warrant that resulted in this arrest arises from a case in which the respondent has an unpaid judgment, the cash
bond may be transmitted to the creditor holding the judgment. By depositing the cash bond with the officer and accepting
this receipt, the depositor waives a claim to the money under the cash bond following its disposition as ordered 
by the court.

Date

Officer

                                        

Signature of depositor of money

        

Department

      

Department receipt number

gency file no.

 A

 
 
 

 A

 
 
 
 
 
 

Date of arrest

rresting agency and address

In the matter of 
 
 

   

v

RECEIPT

STATE OF MICHIGANJUDICIAL CIRCUITJUDICIAL DISTRICTCOUNTY CASH BONDCASE NO. and JUDGECourt addressCourt telephone no.Approved, SCAOForm MC 92 , Rev. 5/21MCL 600.1701 MCR 3.604Page 1 of 2Distribute form to:CourtRespondentArresting agencyDepositor Cash Bond 
Page 2 of 2

(5/21) 

Case No. 
 

TERMS AND CONDITIONS

To secure my release from custody until the court hearing, I promise:

1. I will personally appear at the time and place as directed by the court.

2. I will immediately notify the court in writing of any change in my address or telephone number.

I understand that at the hearing the court will determine how much of the bond money will be applied to any outstanding
judgment in this case and how much, if any, will be returned to the depositor.

I understand that if I fail to appear, the court will issue a bench warrant for my arrest and the bond money posted may 
be forfeited or applied to any outstanding judgment in this case.

Signature of respondent

Address of respondent

City, state, zip

                                                                                                     

          

Date

          Employer

           

Employer’s address

City, state, zip