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 .