DECLARATION FORM

IN THE COURT OF JUDICIAL MAGISTRATE FIRST CLASS AT

_________________ GOA.
Application No. of 20….

(In ref: Case No. of 20….

(Remand Application of the Police Station)

Complainant
V/S
Accused

I,_______________________________________________________________________
________________________________________________________________________

Solemnly affirm and state as follows:-

1. I beg to offer myself as a Surety for Accused
________________________________________________________________________
________________________________________________________________________

(Full name of the accused) who is charged under section

________________________________________________________________________
and who has been ordered to be released on bail in the sum of Rs._______________/-
(Rupees _________________________________________________________________
only) with the ____________________________________________________________
______________________________________ Surety / Sureties in the like amount, by the
___________________________________________________Court/ by Your Honour on
_____________________.

2) I give below certain particular concerning myself:-

(A) Full name of Surety:

Qualification, if any:
Full residential Address:

Period for which Surety has been residing at the above address:
Rent paid for the residence:

Whether the rent bill of the premises stands in the Surety’s name:

(B) Occupation or Business:

Full business address:

Nature and extent of business and Surety’s share therein:

Rent paid for the place of business:

 -2-
Whether the rent bill of the place of business
stands in the Surety’s name:

(C) Name and address of the employer

if the Surety is in service:

Full address of the place of service:

Amount of monthly pay and allowances drawn:

Length of service with the employer:

Amount of Provident Fund, if any, at Surety’s Credit:

(D) Full particulars of house-property owned,

if any, its location, rate able value, and the
surety’s share of interest therein and
whether it is in any way encumbered:

(E) Amount of Income Tax paid during each of the

last three years:

Banking accounts, if any:

Amount now lying in each banking account:

(F) Length of time for which the Surety has

known the Accused personally:

Whether the Surety is related to the accused, if so, how?

Whether the Surety has stood surety for any other person
in the preceding six month. If so, state the names of the
parties, the amount for which the surety has stood for them,
the court and the number of the case against those persons
are pending or have concluded:

Whether the Surety has, at any time,

had his surety bond forfeited:
If so, give particulars:

Whether the Surety has, at any time made an application for

surety ship which was rejected, if so, give the particular thereof:

Whether the Surety is, (or has been) involved

in any civil litigation:
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Whether the Surety himself has been concerned
in any case as an accused person, if so, give
particulars of the case.

3) I produce the following proof in support of the

statement and give particular of the as under:

(Rent bills of place of residence):

(Ration Card) :

(Rent bills of place of business):

(Deed of partnership or the other documents

relating to business) :

(Certificated from the employer):

(Certificate of amount in the Provident Fund):

(Title Deeds of properties):

(Municipal bill of the properties):

(Bank pass books):

(Income tax payment receipts):

(Other proof):

4) I pray that I may I may be accept as a Surety for the above mentioned Accused
in the sum of Rs. _________________________( Rupees ____________________
____________________________________________________________ only).

5) I hereby declare that I have not stood surety in any other pending case or cases.

Solemnly affirmed at _______________________________ on this _______day of

___________________2012.

(Signature of Surety)
Identified by: ___________________________________

Advocate

BEFORE ME

JUDICIAL MAGISTRATE, F. C.

______________________ GOA