Form Bishca 2/2012 Ia - Vermont Surety Bond Form (Page 2 of 3) in pdf

Form Bishca 2/2012 Ia - Vermont Surety Bond Form Page 2

receipt by the Department of Banking, Insurance, Securities and Health Care Administration of said

written notice along with sufficient proof of notice to the Principal.

It is understood and agreed that any person(s) having a claim under the conditions of this obligation may

initiate suit in any Vermont court or any other court of competent jurisdiction against the Principal and/or

the Surety upon this Bond.

WITNESS OUR SIGNATURES, this _____________day of ____________________, ____________.

_________________________________________

PRINCIPAL

(CORPORATE SEAL,

IF APPLICABLE)

_____________________________________________________________

SURETY

(CORPORATE SEAL,

IF APPLICABLE)

_____________________________________________________________

Attorney in Fact

ACKNOWLEDGEMENT OF INDIVIDUAL

STATE OF ______________________________)

ss.

COUNTY OF ____________________________)

On this __________ day of _______________, 20______, before me personally appeared

______________________________, to me known to be the person described in and who

executed the foregoing instrument, as Principal, and acknowledged to me that she/he executed

the same as his/her free act and deed.

(NOTARIAL SEAL)

__________________________________________________

Notary Public

__________________________________________________

County, ___________________________________________

My commission expires _____________________________

BISHCA 2/2012 IA

Form Bishca 2/2012 Ia - Vermont Surety Bond Form Page 2