Form 72a301 - Motor Fuels License Bond printable pdf download

Surety Company Bond

72A301 (10-06)

Number

MOTOR FUELS LICENSE BOND

Commonwealth of Kentucky

DEPARTMENT OF REVENUE

Effective Date of

Issuance

KNOW ALL MEN BY THESE PRESENTS, That we _______________________________________________________________ ,

Name of Principal

________________________________________ , _________________________________________ , ___________________ ,

Number and Street or Highway

City

State and ZIP Code + 4

as principal, and _____________________________________________________________________________________________ ,

Name of Surety Company

________________________________________ , ________________________________________ , ___________________ ,

P.O. Box, Number and Street or Highway

City

State and ZIP Code + 4

as surety, are held and firmly bound unto the Commonwealth of Kentucky in the sum of

________________________________________________ Dollars,

for the prompt filing of all reports and the payment of all taxes, penalties and interest, well and truly to be made, we bind ourselves, our

heirs, administrators, and assigns firmly by these presents.

The condition of this obligation is such that whereas the principal is now engaged in, or is about to engage in, business as a

(check only one)

Gasoline dealer under the provisions of Kentucky Revised Statute Chapter 138

Special fuels dealer under the provisions of Kentucky Revised Statute Chapter 138

Liquefied petroleum gas dealer under the provisions of Kentucky Revised Statute Chapter 234

Motor fuels transporter under the provisions of Kentucky Revised Statute Chapter 138

in the Commonwealth of Kentucky, and as such, will become obligated to the Commonwealth of Kentucky for the collection and

payment of the tax, penalties, and interest, as provided by Kentucky Revised Statutes, which sections impose certain duties, obligations

and liabilities.

NOW, THEREFORE, if said _______________________________________________ shall well and truly pay and account

Name of Principal

to the Commonwealth of Kentucky for taxes, penalties and interest as may become due and owing the Commonwealth of Kentucky by

said ____________________________________________________ in the amounts and in the manner and at the times required by

Name of Principal

statute, and shall make such monthly reports as are required by statute, and furnish such information as may be required by the Kentucky

Department of Revenue, and shall keep and preserve open for inspection by the Department of Revenue such records, papers and files as

the department may require and shall fully and faithfully comply with the terms of the law and the regulations issued pursuant thereto,

then this obligation shall be void; otherwise to remain in full force and effect. Provided, however, this bond can be terminated by the

surety upon written notice to the department, given by certified or registered mail 60 days from the date upon which the surety has lodged

with the Kentucky Department of Revenue a written request to be released.

IN WITNESS WHEREOF, We have hereunto set our hands this _______________ day of _____________ , __________ .

Principal Name

Surety Name

Signature of Owner, Partner or Corporate Officer

Signature of Surety's Authorized Representative

Signature of Additional Partners

Signature of Surety Company Kentucky Resident Agent

Signature of Additional Partners

Resident Agency Name and Mailing Address

NOW, THEREFORE, upon default on any of the obligations secured by this bond, the principal hereby waives its right to

confidentiality under the provisions of Kentucky Revised Statute 131.190 pertaining to any information in the possession of the Ken-

tucky Department of Revenue that relates to the particular default, whereby the Kentucky Department of Revenue is attempting to collect

the amount due from the surety company. The principal authorizes the Kentucky Department of Revenue to release to the surety com-

pany any information, stated above, necessary to determine the surety company's obligation to pay on behalf of the principal.

IN WITNESS WHEREOF, We have hereunto set our hands this _______________ day of _____________ , _________ .

Signature of Owner, Partner or Corporate Officer

Form 72a301 - Motor Fuels License Bond

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