Surety 3 General Agency 625-2 Cassat Ave. Phone: 904-422-97971 Jacksonville, Fla. 32205 Fax: 901-355-5516 APPLICATION FOR NON-LIABLE SUB-AGENT APPOINTMENT You must answer every question on the Application. If a question does not apply, indicate N/A in the space provided for the answer. Your answers are not limited to the space provided on the Application. Attach additional pages as needed. Surety 3 General Agency LLc will not process incomplete Applications. Additional information may be requested. (PLEASE TYPE OR PRINT ALL INFORMATION ON THIS APPLICATION) Employer Information Agency/Employer Name Agency Owner Name Agency Phone # Agency Address Agency Address Section 1: Application Information Applicant Name Applicant Home Address # & Street City County State Zip Date of Birth Place of Birth U.S. Citizen (yes) (no) Form PSC.5 136 Non-Liable Sub-Agent Appointment (10-2012) 1
Surety 3 General Agency 625-2 Cassat Ave. Phone: 904-422-97971 Jacksonville, Fla. 32205 Fax: 901-355-5516 Social Security # Name of Spouse Home Phone # Cell Phone # Do you have a current in-force bail bond license: (yes) (no) License # License expiration date (Attach a copy of current license) How long have you been licensed? What states are you currently licensed in? What states have you been licensed in? List all Insurance Companies and Agents/General Agents that you have issued bail bonds for and/or been appointed with: Dates: From/To Insurance Company or Agent/General Agent Name: Are you engaged in any other business or occupation? (yes) (no) If yes, Nature of business: Name & Address of Business: How long? Owner s Name: Have you ever-declared bankruptcy: (yes) (no) (If yes, attach an explanation.) Section II: Applicant Education Highest level of education achieved: High School; Associate; Bachelors; Advanced. Major: Name of Institution: Date Graduated: Form PSC.5136 Non-Liable Sub-Agent Appointment (10-2012) 2
Surety 3 General Agency 625-2 Cassat Ave. Phone: 904-422-97971 Jacksonville, Fla. 32205 Fax: 901-355-5516 Section III: Applicant Criminal and Regulatory History Have any disciplinary actions ever been taken by any regulatory agency against you, your business or any business with which you have been directly connected? (yes) (no) (If yes, attach a full explanation.) Have you ever had your bail contract cancelled by a surety or general agent? (yes) (no) (If yes, please attach specific information surety name, reasons, when, etcetera.) Have you ever been arrested, charged, convicted of or pled nolo conterdere (no contest) to a felony, gross misdemeanor or a misdemeanor involving moral turpitude or currently have pending any misdemeanor or felony charges against you? (Misdemeanor does not mean minor traffic violations.) (yes) (no) (If yes, please attach detail explanation giving dates, names and address of courts, basis of charges, outcomes and whether you received an executive pardon.) RE: TITLE 28 PRIVACY ACT, FREEDOM OF INFORMATION ACT, TITLE 6 FAIR CREDIT REPORTING PUBLIC LAW 91-508 I understand that investigative inquiries are to be made on myself including consumer, criminal, driving and other reports. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. I also understand that you will be requesting information from various federal, state and other agencies which maintain records concerning any past activities relating to my credit, criminal, civil and other experiences as well as claims involving me in the field of insurance. I authorize, without reservation, any party or agency contacted to furnish the above-mentioned information about me to you. I have a right to make a written request within a reasonable period of time to receive additional information about the nature and scope of this investigation. I hereby consent to your obtaining the above information and agree that, if appointed with you, such information you obtain along with information relating to my performance with you will be accessible through you by future insurance companies to which I might apply. I certify that each statement therein made is full, true and correct to the best of my knowledge. I agree that pursuant to the Violent Crime Control and Law Enforcement Act of 1994, 18 United States Code Sections 1033, 1034, I will notify Surety 3 General Agency, in writing, within 30 days of my being convicted of a felony. APPLICANT SIGNATURE DATE SIGNED Form PSC 136.5 Non-Liable Sub-Agent Appointment (10-2012) 3
Surety 3 General Agency LLC 625-2 Cassat Ave Jacksonville, Fla 32205 Phone: 904-422-9797 Fax: 904-355-5516 W-9 INSTRUCTIONS ALL BUF ACCOUNTS WILL BE IN THE AGENT NAME - NOT THE CORPORATE OR BUSINESS NAME DO NOT USE YOUR CORPORTE EIN# PLEASE FILL OUT AND SIGN WHERE INDICTED. CHECK THE BOX MARKED INDIVIDUAL/SOLE PROPRIETOR USE YOUR SOCIAL SECURITY NUMBER
Form W-9 (Rev. December 2011) Department of the Treasury Internal Revenue Service Name (as shown on your income tax return) Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. Print or type See Specific Instructions on page 2. Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification: Individual/sole proprietor C Corporation S Corporation Partnership Trust/estate Exempt payee Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) Other (see instructions) Address (number, street, and apt. or suite no.) Requester s name and address (optional) City, state, and ZIP code List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on the Name line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Social security number Employer identification number Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4. Sign Here Signature of U.S. person General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners share of effectively connected income. Date Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: An individual who is a U.S. citizen or U.S. resident alien, A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, An estate (other than a foreign estate), or A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No. 10231X Form W-9 (Rev. 12-2011)
Palmetto Surety Corporation 126 Seven Farms Drive, Suite 170 Charleston, SC 29492-7595 Office: (843) 971-5441 Fax: (843) 971-5419 BUF Account Set up Requirements Fill out the following information so that your BUF (Build Up Fund) account can be set up to your desired specifications. Agent Number (not required): Agent Name: Name requested to open Account/Statement:_ (If different from above) Address to send bank Statement: Date: Social Security Number/Tax ID Number (EIN): *Make checks payable to name requested to open the account. Attach completed and signed W 9 Form with a legible copy of your driver s license. IN WITNESS WHEREOF: I fully understand this BUF account is open in accordance with my Bail Bond Agreement between agent and Palmetto Surety Co. This BUF account will be opened using my SS# or Federal Tax ID #. Agent, as owner of the account, will pay all taxes due and payable with respect to income with this account. Palmetto Surety Company, as the trustee and signer on the account, is the sole authority to withdraw funds or close the account. NAME STATE OF COUNTY OF On before me, the undersigned, a Notary Public in and for said County and State, personally known to me to be the person(s) whose name is subscribed to the within instrument and acknowledged that he executed the same. Witness my hand and official seal. Notary Public My commission expires:_ Palmetto Surety Company - BUF Account Set-Up (12/2012) Form PSC-145