210 Pa. Code r. 1751
A bond under this chapter may be in substantially the following form:
(Caption)
Appellant, having appealed from an order of the Court of Common Pleas of _________________ County [or "of the _______ Judicial District"], entered in this matter on the ___ day of ___, 19 ______, and having procured the execution of this instrument for the purpose of complying with the Pennsylvania Rules of Appellate Procedure, the undersigned surety acknowledges itself bound and indebted to the Commonwealth of Pennsylvania, for the use of the persons or parties entitled thereto, in the sum. ____________ dollars ($), to be paid as required by law.
Upon conclusion of this matter, if the appellant satisfies the above identified order or any court order modifying or affirming that order and pays all costs, interest and damages for delay that may be awarded, this obligation shall be void; otherwise, it shall remain in force.
Date ______
____________
(Name of Surety)
By ______________________________________
(Name and Title of Authorized signatory)
210 Pa. Code r. 1751