Cash Bail - Refund Change Of Address Notice Form printable pdf download

C A S H

NYC DEPARTMENT OF FINANCE

TREASURY DIVISION

CASH BAIL REFUND CHANGE OF ADDRESS NOTICE

B A I L

Department of Finance

Mail to: NYC Department of Finance, Treasury/Court Assets Unit, 66 John Street, 12th Floor, New York, NY 10038

Instructions: This form must be completed by the person that paid the Cash Bail (i.e. the Surety). Complete, notarize, and submit

this form along with a valid government picture ID such as a driver’s license, passport, or benefit card. If you do not have a valid gov-

ernment issued ID you will need to provide copies of two (2) forms of ID to verify your identity. At least one ID must have a photo and

signature such as an employment or school ID. Other types of acceptable identification include a utility bill issued within 60 days, an

ATM/Bank Card, or Social Security Card. For additional information visit our Cash Bail/Court & Trust Section at

or contact us at 212-908-7619 or visit us at nyc.gov/contactcashbail.

S E C T I O N I - A P P L I C A N T I N F O R M A T I O N

Print the name of surety/assignee who posted cash in lieu of criminal bail and write the new mailing address where the refund should be sent.

1. Name: ______________________________________________

_________________________________________________

PRINT LAST NAME OF SURETY

PRINT FIRST NAME OF SURETY

2. Former Address: _________________________________________________________________ Apt. #: _________________

(As it appears on the bail receipt)

NUMBER AND STREET

City: ____________________________________________________________ State: ________ Zip Code: ______________

3. New Address: ___________________________________________________________________ Apt. #: _________________

(Where bail refund should be mailed)

NUMBER AND STREET

City: ____________________________________________________________ State: ________ Zip Code: ______________

4. Phone Number: _________________________________ 5. Email Address: ________________________________________

S E C T I O N I I - D E F E N D A N T I N F O R M A T I O N

1. Print the name of the defendant: __________________________________

_______________________________________

LAST NAME

FIRST NAME

2. Print the Docket, Indictment and/or Treasury Receipt Numbers below:

______________________________

________________________________

DOCKET

INDICTMENT

TREASURY RECEIPT

S E C T I O N I I I - C E R T I F I C A T I O N

I certify that I am the above named Surety/Assignee. I authorize the change of my address as indicated above. I understand that any fu-

ture communications and or refunds will be sent to the new address provided. Further, I understand that the Department of Finance is

not liable for any incorrect information provided above that may result in the misuse of my refund. I hereby acknowledge that the infor-

mation provided above is true and correct to the best of my knowledge.

_________________________________________________

Signature of Surety

Sworn to before me

on __________________________________, 20________

Notary

Affix

Stamp

_________________________________________________

Here

Notary Public/Commissioner of Deeds

F O R O F F I C I A L U S E O N L Y

_________________________________________________

_______________________________________________

Court Assets Member Approval and Date

Supervisor Approval and Date

Visit Finance at nyc.gov/finance

ChgAddr 12.11.2015

Cash Bail - Refund Change Of Address Notice Form

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