Pursuant to Florida Statutes § 903.14(3), every bail bond agent who accepts collateral security for a bail bond may make, attach to and file with each bail bond, in lieu of the affidavit required by Fl. Admin. Code R. 69B-221.125, a statement on a form prescribed by the Department, to wit:
STATEMENT
    I, ___ am a duly licensed bail bond agent pursuant to chapter 648, F.S., and have registered for the current year with the office of the Sheriff and Clerk of the Circuit Court of the aforementioned county, and have filed a certified copy of my appointment by Power of Attorney for the Surety with the office of the Sheriff and Clerk of the Circuit Court of the aforementioned County. That ___ (Principal) of ___ (Address) has (given or promised to give) the sum of ___ ($) Dollars as consideration for Bail Bond Number ___ filed with the Clerk of the ___ located in ___ together with the (promise or receipt) of security belonging to ___ (Name) of ___ (Address) as follows: (Provide detailed description and source of security) ___
    That a duly signed receipt has been given to the said ___ (Principal) for the consideration given and/or that the said ___ (Name) has (also been) given a receipt for the security described above.

________________________________

(Bail Bond Agent)

________________________________

(Agency)

________________________________

(Address)
Rulemaking Authority 648.26, 648.442(9) FS. Law Implemented 903.14(3), 648.36, 648.44(1)(m), 648.442, 648.45 FS. History-New 7-1-69, Repromulgated 12-24-74, Formerly 4-1.141, Amended 9-10-91, Formerly 4-1.0141, Amended 4-14-97, Formerly 4-221.130.