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PLC:

a003fz

Agency:

broomfield police detention center

For:

remote bond

Phone:

720-887-2000

Address:

11600 ridge parkway
broomfield, colorado 80021

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*The cardholder acknowledges that he/she relinquishes any claim to these funds and understands and agrees that these funds will become the property of the defendant.:

*Furthermore, the cardholder understands that upon disposition of the charges/cases against the defendant, any funds ordered returned by the court will be returned to the defendant and not the cardholder.:

*Defendant Name:

Middle:

*Last:

*Date of Birth:

(Month / Day / Year)

Notes:

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Subtotal:

$0.00

Total:

$0.00

Billing Information

*First Name:

Middle Initial:

*Last Name:

*Billing Address:

*City:

*State/Province:

*Zip:

*Country:

*Phone Number:

*Credit/Debit Card:

(enter the full card number without any dashes or spaces)

*Expiration Date:

*Card Security Number:

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