___公(    )行没字[    ]第___号

                                     保证金交纳人________________性别_____出生日期_____
                                     保证金金额________________________________________
                                     没收原因  ________________________________________
                                     承 办 人 _________________________________________
                                     批 准 人 _________________________________________
                                     填 发 人  ________________________________________
                                     填发日期  ________________________________________

                                                存根