______公安局
                                       对保证人罚款段收保证金复核决定书 
                                                    （存 根）
                                                    字[ ] 号
                                   案件名称：________________________________

                                   案件编号：________________________________
                                   保证人：________性别：________年龄：______
                                   住址：____________________________________
                                   被取保候审人：_______ 性别：____年龄：____
                                   罚款原因：________________________________
                                   罚款数额：________________________________
                                   批准人：__________________________________
                                   批准时间：________________________________
                                   办案人：__________________________________
                                   办案单位：________________________________
                                   填发时间：________________________________
                                   填发人：__________________________________