Form 74 075 991 – Fill Out and Use This PDF

of			as principal and
of					as Surety

Are held and firmly bound unto the State of Mississippi in the just and full sum of

dollars, for the payment of which sum well and truly to be made and done, we bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally by these presents.

WHEREAS, the said principal obligor herein has applied to the Department of Revenue for a permit to engage in business as a Distributor of Gasoline, Special Fuel, Lubricating Oil, or Compressed Gas, in the State of Mississippi; and/or has applied for a Contractor’s Direct Pay Permit for Special Fuel under the Laws, Rules and Regulations of the State of Mississippi as now or hereafter amended creating and regulating such distributors and contractors.

NOW THEREFORE, the condition of this bond is that the principal obligor herein shall comply with all provisions of the Laws, Rules and Regulations of the State of Mississippi, as now or hereafter amended, pertaining to Distributors of Gasoline, Special Fuel Lubricating Oil, Compressed Gas, or either as defined by statue and/or contractors holding direct pay permits for Special Fuel and shall pay all excise taxes and penalties provided for or required by the Law, Rules or Regulations of the State of Mississippi, as now or hereafter amended until the bond hereby executed is cancelled in the manner provided for herein.

It is a further condition of this bond that on notice of the Department of Revenue of the State of Mississippi, that said principal obligor herein is delinquent under the Laws, Rules, and Regulations of the State of Mississippi pertaining to Gasoline, Special Fuel, Lubricating Oil, Compressed Gas, and/or Contractors Direct Pay Permits for Special Fuel, said principal will immediately pay the Department of Revenue for the benefit of the State of Mississippi, all taxes, interest, penalties and such other fees or expenses, including attorney’s fees, as might be incurred in collecting the amount demanded, and on failure so to do, said principal obligor hereby authorizes and directs said Surety to make payment, not to exceed the limits of this bond for the account of said principal obligor, and the said Surety, agrees to pay the same immediately.

The Surety shall have the right to cancel this bond upon written notice personally served upon an appropriate representative of the State Tax Commission, or sent by registered mail to said Department of Revenue, specifying therein the effective date of such cancellation. Such date shall not be less than sixty (60) days after the date of service, or if sent by registered mail, not less than sixty (60) days after the date borne by the sender’s registry receipt. Provided, however, that the cancellation of this bond shall not relieve the principal obligor or his Surety herein from liability on said bond for default occurring prior to the date of said cancellation.

SIGNED, SEALED AND DELIVERED, this the				Day of		,
Mississippi Resident Agent				Principal
Insurance Company Name			Owner, Agent or Officer
Mailing Address				Surety

City

State

Zip

Attorney-in-Fact