Form Wv/mft-510 - Motor Fuel Excise Tax Surety Bond Page 2
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4ACKNOWLEDGEMENT BY PRINCIPAL IF INDIVIDUAL, LLC, OR PARTNERSHIP (Must be completed if you qualify)
(15)
State or Commonwealth of _________________________
(16)
County of _________________________, to-wit:
(17)
I, ___________________________________ a Notary Public in and for the county and state aforesaid, do hereby certify that
(18)
_________________________________________ whose name is signed to the foregoing writing,
(19)
bearing date the __________ day of ______________, 20________has this day acknowledged the same before me in my said county.
(Bearing date and execution date on Line 8 must be the same)
(20)
Given under my hand this the __________ day of _______________, 20 ________.
(21)
Notary Seal
(22) __________________________________
Notary Public
(23)
My Commission expires on the __________ day of _______________, 20 __________.
ACKNOWLEDGEMENT BY PRINCIPAL IF CORPORATION (Must be completed if you qualify)
(24)
State or Commonwealth of _________________________
(25)
County of _________________________, to-wit:
(26)
I, ___________________________________ a Notary Public in and for the county and state aforesaid, do hereby certify that
(27)
________________________________________, who as
(28)
________________________________________, signed the foregoing writing for
(29)
________________________________________, a corporation,
(30)
bearing date the __________ day of ______________, 20__________,
(Bearing date and execution date on Line 8 must be the same )
has this day, in my said county, before me, acknowledged the said writing to be the act and deed of the said corporation.
(31)
Given under my hand this the __________ day of _______________, 20 ________.
(32)
Notary Seal
(33) __________________________________
Notary Public
(34)
My Commission expires on the __________ day of _______________, 20 __________.
ACKNOWLEDGEMENT FOR SURETY (Must be completed by the Surety Company)
(35)
State or Commonwealth of _________________________
(36)
County of _________________________, to-wit:
(37)
I, ___________________________________ a Notary Public in and for the county and state aforesaid, do hereby certify that
(38)
________________________________________, who as
(39)
________________________________________, signed the foregoing writing for
(40)
________________________________________, a surety company,
(41)
bearing date the __________ day of ______________, 20__________,
)
(Bearing date and execution date on Line 8 must be the same
has this day, in my said county, before me, acknowledged the said writing to be the act and deed of the said corporation.
(42)
Given under my hand this the __________ day of _______________, 20 ________.
(43)
Notary Seal
(44) __________________________________
Notary Public
(45)
My Commission expires on the __________ day of _______________, 20 __________.
Sufficiency in Form and Manner of Execution Approved
State Representative
Dated this__________ day of _______________, 20 ________.
_______________________________________________
Signature and Title
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