(Section 436, 437, 438 (3) and 441Cr.P.C.)
In the Court of Shri _______________________________________
Police Station : Next date of hearing _____________
Under Section : Sent to Jail on _____________
F.I.R. No. :
I, _________________________ son of Shri ___________________________________ Resident of _____________________________________________________________having been arrested or detained without warrant by the officer Incharge of ________________________ Police Station for having been brought before this Hon’ble
Court charged with the offence of ________________________ and required to give surety for my attendance before such Officer or Court on condition that I shall attend such officer or Court on every day on which any investigation or trial is held with regard to such charge and in case of my making default there in I hereby bind my self to forfeit to Government the sum of Rs _______________ .
I ___________________________ son of Shri _____________________________ Resident of _________________________________________________________hereby declare myself for the above said Shri ________________________________that he shall attend the officer-in-charge of _________________________________Police Station or the Court of Shri ________________________________________every day on which any investigation in the charge is made or any trial on such charge is heldthat he shall be and re-appear before such officer or Court for the purpose of such investigation to answer the charge against him (as the case may be) and in the case of his making default herein I have bind myself to forfeit to Government the sum of Rs. __________ .
Dated this _______________ day of _____________ 200___.
2. __________________ Signature