Indiana State Form 415 23 – Fill Out and Use This PDF

PERMIT BOND

State Form 415 23 (R4 / 3-00)

Approved by State Board of Accounts, 2000

STATE OF INDIANA

DEPARTMENT OF TRANSPORTATION

Driveway

Excavation

Pole Line

Bridge Attachment

Misc.____________________

Know all men by these presents that we, the Undersigned _________________________________________

(address) ___________________________________________________________________as Principal and

_________________________________________________________________________________________

(address) ___________________________________________________________________as Surety, are

hereby held and firmly bound unto the State of Indiana in the penal sum of ____________________ , for the

payment of which well and truly to be made, we hereby jointly and severally bind ourselves, our heirs, executors, administrators successors and assigns:

DATED THIS ____________________________________ .

The conditions of the above obligation are such that, whereas, the above named _______________________

_________________________________________________________________________________________

did on ____________________________________ make application for a permit with the State of Indiana for:

__________________________________________________________________________________________

__________________________________________________________________________________________

which permit is made a part of this bond the same as though set forth herein.

Now, if said ________________________________________ (Principal - Applicant) shall well and faithfully do

and perform the things agreed by the _________________________________________ (Principal - Applicant)

to be done and performed according to the terms of said permit and to the satisfaction of the Indiana Department of Transportation, and shall pay all lawful claims of the contractor, vendors and laborers for labor performed and materials furnished, or other services rendered in the carrying forward, performing and completing of said permit, (on file with the Department of Transportation), then this obligation shall be void, otherwise the same shall remain in full force and effect, it being expressly understood and agreed that the liability of the Surety for any and all claims hereunder except as provided below shall in no event exceed the penal sum of this obligation as herein stated. In event of noncompliance the surety shall be liable for the court costs and attorney fees spent in the collection of this bond over and above the penal sum of this obligation.

IN WITNESS WHEREOF, we hereunto set our hands and seals this _________________________ day of

___________________, 20 ____
__________________________________________	_____________________________________________
__________________________________________	_____________________________________________
Surety	Principal
(Attach Power of Attorney)
State of __________________________________ ,	County of _________________________________ ss:

Personally appeared before me, ____________________________________________________________

______________________________as Principal and______________________________________________

___________________________________as Surety and each acknowledged the execution of the above bond

this___________________day of _______________________ , 20______

Witness my hand and _________________________________seal the said last named date.

My Commission Expires______________________, 20_____		_____________________________________
		Notary Public (Written Signature)
I reside in _____________________________County, ______		_____________________________________
	(State)	Notary Public (Printed or Typed Name)
Bond number	NOTICE OF TERMINATION OF LIABILITY

□COMPLIED □ CANCELLED ___________________________________, 20 _____

DATE

Submit all 5 copies By: ___________________________________________________________________

PERMIT MANAGER

Application number

Road number

County number Received date

Issue date

Permit number