Form R-5304 - Motor Fuels Tax Surety Bond
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1R-5304 (10/15)
Bond Number
Mail to:
Motor Fuels Tax
Taxpayer Compliance - SSEW
Surety Bond
P.O. Box 66362
Account Number
Baton Rouge, LA 70896-6362
KNOW ALL MEN BY THESE PRESENTS, That we,
PRINCIPAL:
_______________________________________________________________________________________________________
(Legal Name of Business)
Trade Name of Business:
____________________________________________________________________________________________
Principal Location of Business:
_______________________________________________________________________________________
(Street Address, City, and State)
Mailing Address:
___________________________________________________________________________________________________
(Box or street, City, State)
Ownership
If corporate, show state of domicile
__________________________________________________
______________________
(Individual, Partnership, Corporate, etc.)
Parish/County of
State of
(hereinafter called Principal),
_______________________________,
_________________________________ ,
AND SURETY: _____________________________________________________________________________________________________
(Name of Surety)
__________________________________________________________________________________________________________________
(Mailing Address of Surety)
(herinafter called Surety), are held and firmly bound unto
_________________________________________________________________
Secretary of the Department of Revenue for the State of Louisiana (hereinafter called Secretary), or his/her successors in office, in the
sum of
___________________________________________________________________
Dollars ($
____________________________________);
for the payment of which, well and truly to be made, we bind ourselves, our heirs, executors, administrators and assigns, jointly and
severally, firmly by these presents.
The condition of the foregoing obligation is such that:
Whereas, the said Principal is a
q Terminal Operator
q Supplier
q Permissive Supplier
q Distributor
q Importer
q Exporter
q Blender
q Interstate Motor Fuel User
q Special Fuel Fleet Dealer
q Special Fuel Retail Dealer
as defined in Part V-A of Chapter 7 of Subtitle II of Title 47 of the Louisiana Revised Statutes of 1950, as amended.
NOW, THEREFORE, if the said Principal shall pay all taxes, penalties, interest, and cost levied by, accrued or accruing under said Acts,
to the said Secretary, or to his successors in office, as required by the provisions of said Acts, and shall fully, completely and faithfully
perform all of the conditions and requirements of said Acts in the manner and at the time provided therein; then this obligation shall be
null and void, otherwise to remain in full force and effect.
This bond shall be effective on and after __________________________________________ and is a continuing bond and may be
terminated by either the Surety or Principal by giving the other thirty (30) days notice of such intention of termination, such notice to be
filed with said Secretary; but such termination of liability shall not relieve the Surety of any liability on any claim or claims known, or claim
or claims which might arise, and for which the Surety would be liable before the effective date of said notice of termination.
This bond is authorized by and made pursuant to Part V-A of Chapter 7 of Subtitle II of Title 47 of the Louisiana Revised Statutes of
1950, as amended, and all provisions of said Laws are hereby made part of this bond.
IN FAITH WHEREOF, we have signed these presents at the place and on the date hereinafter indicated.
WITNESS:
PRINCIPAL:
(1) __________________________________________________
_____________________________________________________
(Signature)
(Legal Name of Business)
_____________________________________________________
Signed by: ____________________________________________
(Print Name)
(Signature)
(2) __________________________________________________
_____________________________________________________
(Signature)
(Print Name)
_____________________________________________________
Title: _________________________________________________
(Print Name)
Signed at: ________________________________________
on the _____________day of ____________________, 20______
(City, State)
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
WITNESS:
SURETY:
(1) __________________________________________________
_____________________________________________________
(Signature)
(Legal Name of Surety)
_____________________________________________________
Signed by: ____________________________________________
(Print Name)
(Signature)
(2) __________________________________________________
_____________________________________________________
(Signature)
(Print Name)
_____________________________________________________
Title: _________________________________________________
(Print Name)
Signed at: ________________________________________
on the _____________day of ____________________, 20______
(City, State)
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