State of Tennessee,
County of ____________________.
I, ______________, principal, and ______________, sureties, do hereby agree to pay the State of Tennessee, for the use of ____________________ county, the sum of ____________________ dollars, in monthly installments of ____________________ dollars, to be paid on the ____________________ day of each month, until the whole is paid, this being the amount for which ______________ is confined in the ____________________ county workhouse. ______________ agrees to be bailed out of the workhouse by above parties, and agrees to work out or pay the amount above specified as therein stated, at the office of the county mayor. Should ______________ fail to do so, then ______________ is liable to be arrested and delivered to the superintendent of the workhouse, to work out any balance unpaid and the costs of the arrest. In case of default and arrest, the bailee is only liable for the amount falling due prior to the arrest.
This ____________________ day of ____________________, 20____________________.
T.C.A. § 41-2-126