IN THE COURT OF……

State vs ………….

BOND

I , --------- s/o --------- r/o -------- , have been convicted by this Hon’ble court for a period of ----------
months/years and also with a fine of Rs. ---- u/s -----, vide FIR No.---- P.S------

I, ---- intend to prefer an appeal before the Hon’ble Session court/ High court. I undertake to
obtain a stay against the above order of conviction by –one month period from today—failing which I
undertake to surrender before this Hon’ble court on ----. In case I fail to do so , I shall forfeit to this
Hon’ble court a sum of Rs.----

Delhi signature of the convict

Dated