公（　 ）行退通字[　　]第　号

                             被通知____________________________________________
                              保证金交纳人___________性别_______出生日期________
                              被担保人 _________________________________________
                              保证金金额　______________________________________
                              取保日期　________________________________________
                              承 办 人 _________________________________________
                              批 准 人 _________________________________________
                              填 发 人 _________________________________________
                              填发日期 _________________________________________

                                          存根