Third Party Custodian ID: 1039299
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4 4 4 4 4 4 Save Print UNITED STATES PRETRIAL SERVICESWESTERN DISTRICT OF TEXASTHIRDPARTY/COSURETYVERIFICATION FORM DEFENDANT’S NAME__________________________________DATE___________________ NAME (INCLUDE ALIASES/MAIDENNAME): DOB: ___________________ SOCIAL SECURITY #: _____________________ ADDRESS: Street CityStateZip Code MAILING ADDRESS: StreetCityStateZip Code DRIVER’S LICENSE STATEUMBER: CITIZENSHIP: USC __________NATURALIZED ___________RESIDENT ALIEN # MARRIED:: NO: SPOUE’S NAME: RELATIONSHIP TO THE EFENDANT:_ LENGTH OF TIME YOU HAVE KNOWN THE DEFENDANT:_______________________________ EMPLOYER: _______________________________ PHONE NO.___________________________ ADDRESS: LENGTH OF TIME WITH EMPLOYER HAVE YOU EVER BEEN ARRESTED/CONVICTED OF AN OFFENSE? YES_______ NO________ IF YES, EXPLAIN:________________________________________________________________ IS ANYONE LIVING AT YOUR RESIDENCE AN ILLEGAL ALIEN? YES_______ NO________ IF YES, WHO AND WHAT IS THEIR RELATIONSHIPTO THE DEFENDANT DO YOU HAVE A MEDICAL CONDITION THAT MAY PREVENT YOU FRM SERVING AS A THIRDPARTY CUSTODIAN?YES_______ NO________ INFORMATION NEEDED FOR CO ASSETS: LIABILITIES: ARE YOU WILLING TO PROVIDE PROOF OF ASSETS AND/OR LIABILITIES: YES_____NO SURETY/THIRD PARTY SIGNATURE DATE: ACCEPTED AS COSURETY: YES______ ACCEPTED AS THIRDPARTY CUSTODIAN: YES______