Form Wv/mft-510 - Motor Fuel Excise Tax Surety Bond printable pdf download

WV/MFT-510

BOND NUMBER: __________________________

Rev. 2/10

WEST VIRGINIA STATE TAX DEPARTMENT

TAX ACCOUNT ADMINISTRATION DIVISION

EXCISE TAX UNIT

1001 LEE STREET, EAST

PO BOX 2991

CHARLESTON, WV 25330-2991

MOTOR FUEL EXCISE TAX SURETY BOND

KNOW ALL MEN BY THESE PRESENTS:

(1)

That we, (Principal): __________________________________________________________________________________________

(2)

Address: ___________________________________________________________________________________________________

(3)

As Principal, and (Surety Company): _____________________________________________________________________________

(4)

Address: ___________________________________________________________________________________________________

a firm and/or a corporation authorized to do business in the State of West Virginia, as Surety, are held and firmly bound unto the State

(5)

of West Virginia in the just and full sum of ___________________________ dollars ($________________________) to the payment

whereof well and truly to make, we bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally,

firmly by these presents.

(6)

WHEREAS, the above bound Principal is a ________ Supplier, ________ Permissive Supplier, ________ Terminal Operator,

________ Importer, ________ Distributor, ________ Blender, or ________ Exporter of motor fuel within the meaning of Chapter 11,

Article 14C, of the Official Code of West Virginia of 1931, as amended, and whereas the Tax Commissioner of the State of West

Virginia has required the said Principal to deposit a bond, in accordance with the provisions of Chapter 11, Article 14C, Section 13 of

the said Code of West Virginia;

NOW THEREFORE, if the said Principal shall in all respects fully comply with provision of Chapter 11, Article 14C, of the

said Code of West Virginia and the rules and regulations adopted and promulgated thereunder, and shall account for and pay over all

motor fuel taxes and penalties for which the said Principal shall be liable, and shall protect and save harmless the State of West

Virginia from any loss arising from the failure of the Principal to pay such motor fuel taxes and penalties, for any cause whatsoever,

then this obligation to be void; otherwise to remain in full force and effect unless any of the signatories hereto give written notice by

registered mail to the other signatories hereto that the signatory desiring the cancellation intends to cancel this bond sixty (60) days

after the post-mark date of the written registered notice. An annual notice of renewal is not required.

The principal hereby waives the secrecy provisions of West Virginia Code §11-10-5(d) and authorizes the Tax Department to

release to the surety company information necessary to file proof of claim, concerning any tax liability covered by this bond and

accruing during the effective dates of this bond.

(7)

This bond shall be effective from the __________ day of _______________, 20__________.

IN WITNESS WHEREOF the said principal has hereunder set his or its hand and affixed his or its seal, and the said surety has

caused its corporate name to be signed hereto and its corporate seal to be hereunto affixed by its duly authorized officer or agent and

(8)

executed this instrument this __________ day of _______________, 20 _________.

(9) ___________________________________________________________

(Principal)

(10) By: _______________________________________________________

Title: Must be President or Vice-President or authorized individual

Affix: Principal Corporate Seal

(11)

(A drawn facsimile is acceptable if no corporate seal)

(LLC’s are not required to provide a seal)

________________________________________________________

(10)

(Print Name of Person Signing)

(12) ___________________________________________________________

(Surety Company)

(13) By: _______________________________________________________

(Title)

Affix: Surety Corporate Seal

(14)

Form Wv/mft-510 - Motor Fuel Excise Tax Surety Bond

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