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Mississippi Bail Fund Request
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* Indicates required question
Referrer's Name
*
Your answer
Referrer's Phone Number
*
Your answer
Referrer's Email
Your answer
Referrer's relationship to the person needing assistance.
Parent
Sibling
Spouse
Friend
Advocate
Other:
Clear selection
Person's Name
*
Your answer
Person's Date of Birth
*
MM
/
DD
/
YYYY
Person's Age
Your answer
Arresting Agency
*
Your answer
County
Your answer
Date Arrested
MM
/
DD
/
YYYY
Name of Facility where person is being held
*
Your answer
Charges
*
Your answer
Enter the
TOTAL
amount of bond. For example, if the bond is set at $20,000 enter $20,000,
NOT
10% of the total amount due.
Your answer
Does this person have housing upon release?
Yes
No
Maybe
Clear selection
To your knowledge, does this person have any of the following:
*
Failure (s) to Appear
Holds
Prior Felony Convictions
Other:
Does this person have an attorney?
*
Yes
No
Attorney's Name
Your answer
Attorney's Phone Number
Your answer
Attorney's Email Address
Your answer
Next court date (if known)
MM
/
DD
/
YYYY
Does this candidate need mental health assistance?
Yes
No
Maybe
Clear selection
Please share additional information or resource needs that will help this candidate gain stability after release?
Your answer
Submit
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