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NOTE: By placing my signature below, hereby acknowledge thatl have been advised by Jailor, of my rights
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to be brought before a Magistrate promptly for the above Count(s); That have waived any delay in that right
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and agreed to pay a ne, if eligible, or to appear as scheduled above; That ifI fail to appear as scheduled a
Bench Warrant will be issued for my case and any Bail-Bond posted or future consideration for release on my
own recognizance will be fo eited. have received a copy of this form as my Release Receipt.
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