Form Wv/mft-510 - Motor Fuel Excise Tax Surety Bond Page 4
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4ACKNOWLEDGEMENT PREPARATION INSTRUCTIONS:
(Acknowledgements must be completed where applicable)
•
If Principal is an Individual, LLC, or Partnership: A Notary Public must complete lines (15) through (23).
•
If Principal is a Corporation: A Notary Public must complete lines (24) through (34).
•
Surety Company: A Notary Public must complete lines (35) through (45).
ACKNOWLEDGEMENT BY PRINCIPAL IF INDIVIDUAL, LLC, OR PARTNERSHIP (Must be completed if you qualify)
(15)
Enter name of State or Commonwealth.
(16)
Enter name of County.
(17)
Enter name of Notary Public witnessing transactions.
(18)
Enter name of Principal covered by bond if Individual or Partnership.
(19)
Enter bearing date of bond (also known as execution date).
Must be same date entered on Line 8 of bond.
(20)
Notary Public enters date bond was witnessed. May be same as bearing date or any date thereafter.
(21)
Affix Notary Seal. If Notary Public is located outside of West Virginia, seal must be affixed.
(22)
Notary Public affix signature.
(23)
Notary Public enters commission expiration date.
ACKNOWLEDGEMENT BY PRINCIPAL IF CORPORATION (Must be completed if you qualify)
(24)
Enter name of State or Commonwealth.
(25)
Enter name of County.
(26)
Enter name of Notary Public witnessing transactions.
(27)
Enter name of Corporate Officer signing bond. (Should be President of Vice-President)
(28)
Enter designate Title of Corporate Officer signing bond.
(29)
Enter name of Company or Corporation.
(30)
Enter bearing date of bond (also known as execution date).
Must be same date entered on Line 8 of bond.
(31)
Notary Public enters date bond witnessed. May be same as bearing date or any date thereafter.
(32)
Affix Notary Seal. If Notary Public is located outside of West Virginia, seal must be affixed.
(33)
Notary Public affix signature.
(34)
Notary Public enters commission expiration date.
ACKNOWLEDGEMENT BY SURETY (Must be completed by the Surety Company)
(35)
Enter name of State or Commonwealth.
(36)
Enter name of County.
(37)
Enter name of Notary Public witnessing transactions.
(38)
Enter name of person having power of attorney to bind Surety Company.
(39)
Designate title of person binding Surety Company.
(40)
Enter name of Insurance Company (Surety).
(41)
Enter bearing date of bond (also known as execution date).
Must be same date entered on Line 8 of bond.
(42)
Notary Public enters date bond witnessed. May be same as bearing date or any date thereafter.
(43)
Affix Notary Seal. If Notary Public is located outside of West Virginia, seal must be affixed.
(44)
Notary Public affix signature.
(45)
Notary Public enters commission expiration date.
POWER OF ATTORNEY INSTRUCTIONS
Power of Attorney for Surety must be attached and must show that it was in full force and effect on the bearing date
(execution date) indicated on the face of the bond; also the raised corporate seal must be affixed to the Power of Attorney.
Name of Attorney in Fact must be listed.
Power of Attorney may not exceed imposed limitations.
Certificate date must be the bearing date (execution date) of bond.
Must be same date entered on Line 8 of bond.
Signature of authorizing official must be affixed. (Signature may be a facsimile).
Raised seal must be affixed.
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