Form Wv/mft-510 - Motor Fuel Excise Tax Surety Bond Page 3
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4MOTOR FUEL EXCISE TAX SURETY BOND
Should you require any assistance, please contact the West Virginia State Tax Department, Excise Tax Unit at the following numbers:
(304) 558-8623, (304) 558-8624, (304) 558-8625, (304) 558-8626, or (304) 558-8627.
PREPARATION INSTRUCTIONS
IF PRINCIPAL IS AN INDIVIDUAL, LLC, OR PARTNERSHIP:
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Complete the Motor Fuel Excise Tax Surety Bond, lines (1) through (11);
•
Have a Notary Public complete the applicable section of acknowledgement titled, Acknowledgement by Principal if
Individual, LLC, or Partnership, on the back of bond.
IF PRINCIPAL IS A CORPORATION:
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Complete the bond, lines (1) through (11); Note: (Line 11) a drawn facsimile is acceptable, if no corporate seal.
•
Have a Notary Public complete the applicable section of acknowledgement titled, Acknowledgement by Principal if
Corporation, on the back of bond.
•
Affix corporate seal as requested on face of bond;
SURETY
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Complete the applicable portion of bond;
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Notary Public must complete section of acknowledgement titled, Acknowledgement by Surety (back of bond);
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Attach Power of Attorney to bond if surety signatory is an Attorney In Fact;
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Affix raised Surety Seal to bond and to Power of Attorney.
LINE NUMBER INSTRUCTIONS:
FACE OF BOND CANNOT CONTAIN WHITE-OUTS OR ALTERATIONS. REVERSE OF BOND MAY
CONTAIN WHITE-OUTS OR ALTERATIONS PROVIDING CHANGES ARE INITIALED BY NOTARY.
(1-2)
Enter name and address of Principal (Specify individual, partnership, or corporation) to be covered by bond.
(3-4)
Enter name and address of Surety Company issuing bond.
(5)
Enter amount of bond.
(6)
Enter License Type.
(Supplier, Permissive Supplier, Terminal Operator, Importer, Distributor, Blender or Exporter)
(7)
Enter effective date of bond.
(8)
Enter execution date of bond.
(9)
Enter name of the Principal (individual, partnership, or corporation) covered by bond.
(10)
If principal is an individual, affix signature. If principal is a corporation, President or Vice-President must sign and
print name on bond and underline the appropriate title. If bond is to be signed by one other than the President or
Vice-President, affix a copy of corporate resolutions showing authorization of individual to bind corporation.
(11)
If Principal is a corporation, be sure to affix corporate seal, if not available, draw facsimile.
Note: LLC’s are not required to provide a corporate seal.
(12)
Enter name of Surety.
(13)
Affix signature and title of person having Power of Attorney to bind Surety.
(14)
Affix corporate seal of Surety.
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