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There appearing no bond of record to initiate the matter regarding Case # 0000000 and Warrant # 000000[if applicable] and associated account(s), I, JohnHenry:Doe, undertake as follows: In consideration thereof that no lawful money of account exists in circulation, and in consideration thereof that I have suffered dishonor regarding the matter of Case # 000000 and Warrant # 000000 and associated account(s), I underwrite with my private exemption any and all obligations of performance/loss/costs sustained by the United States of America/State of Colorado and the respectful citizens thereof regarding said matter. Done at [name of county] county, [state], this _____ day of ___________, 20___.