Form R-5304 - Motor Fuels Tax Surety Bond
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1R-5304 (7/06)
Motor Fuels Tax Surety Bond
Mail to:
Taxpayer Services Division
Bond Number:
__________________________
Excise Tax Section
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:______________________________________________________________________________________________
Street Address
City
State
ZIP
Principal Location of Business: ________________________________________________________________________________________
(Street Address, City, and State)
Street Address
City
State
ZIP
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)
Address
City
State
ZIP
__________________________________________________________________________________________________________________
(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
❑ Terminal Operator
❑ Supplier
❑ Permissive Supplier
❑ Distributor
❑ Importer
❑ Exporter
❑ Blender
❑ Interstate Motor Fuel User
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)
City
State
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)
City
State
Signed at: ________________________________________
on the _____________day of ____________________, 20______
(City, State)
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