SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE JUSTICE CENTER: G Central - 700 Civic Center Dr. West, Santa Ana, CA G Harbor-Newport Beach Facility - 4601 Jamboree Rd., Newport Beach, CA G Lamoreaux - 341 The City Drive, Orange, CA G North - 1275 N. Berkeley Ave., Fullerton, CA G West - 8141 13th Street, Westminster, CA G FOR COURT USE ONLY PEOPLE OF THE STATE OF CALIFORNIA VS.

DEFENDANT: AUTHORIZATION TO APPLY THIRD PARTY BAIL CASE NUMBER: TO THE CLERK OF THE COURT: I, __________________________________, hereby authorize the cash bail deposited by me on ________________ to be applied toward the payment of any fine imposed against defendant, ______________________________________, in the above named case and the balance of the deposit, if any, returned to: Name: __________________________________________ Address: ________________________________________ City, State:_______________________________________ Date: _____________________ _______________________________________ Signature of Depositor ................................................................................................................................................................. (To be completed by the Deputy Sheriff/Clerk) I have witnessed the signature and examined the following legal photo identification G Driver License #________________________ ; G DMV Identification Card # ___________________________; G Other (specify): # ______________________________________ .

G DON BARNES, Sheriff-Coroner G DAVID H. YAMASAKI, Clerk of the Court Date: By: By: Deputy Deputy Clerk IF THIS FORM IS RETURNED TO COURT BY MAIL, IT MUST BE NOTARIZED State of _________________________________ County of ________________________________ On ___________________________________, before me, ________________________________________________ the undersigned Notary Public, personally appeared ________________________________________________ personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(

s) whose name(

s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(

s) on the instrument the person(s), or the entity upon behalf of which the person(s), acted, executed the instrument. WITNESS my hand and official seal _______________________________________________ Notary's Signature AUTHORIZATION TO APPLY THIRD PARTY BAIL L-1191 (Rev. 02/26/2019) Form Adopted for Mandatory Use