IN THE DISTRICT COURT OF DOUGLAS COUNTY, KANSAS
) ) Vs. ) ) ) ___________________________________________) STATE OF KANSAS
Case No. ____________________ Division No. _______
BOND RELEASE AUTHORIZATION NOW ON THIS ___________ day of ______________________, ____________, comes the defendant / third party (circle), ___________________________________________________________________(print name), who authorizes the release of bond monies in the sum of $ _____________________________, to the District Court for application toward costs, fees, fines, and/or restitution in this matter, as determined to be appropriate.
________________________________________ Signature ________________________________________ Address ________________________________________ City, State, Zip code ________________________________________ Phone Number