Form Modes-4252 - Surety Bond
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3MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
REQUIREMENTS FOR COMPLETING FORM
DIVISION OF EMPLOYMENT SECURITY
1. Issued by licensed insurance company
421 East Dunklin Street, Post Office Box 59
2. Signed by Attorney-In-Fact
Jefferson City, MO 65104-0059
3. Signed by applicant
SURETY BOND
4. Must bear insurance company seal
(Financial Guarantee for Payment of Contributions)
5. Must have effective date
Bond Number
6. Must be accompanied by a valid Power of
Attorney letter
KNOW ALL MEN BY THESE PRESENTS:
That I/We _________________________________________________________________________________________________
(Owner’s Name)
(Business Name)
of _____________________________________________________County, State of ____________________________________
as principal, and____________________________________________________________________________________________
(Name of Surety Company)
a corporation duly licensed for the purpose of making, guaranteeing or becoming sole surety upon bonds required or authorized by
the laws of the State of Missouri, as surety, are held and firmly bound to the Missouri Department of Labor and Industrial Relations,
Division of Employment Security, in the penalty sum of ____________________________________________________________
____________________________________ DOLLARS ($____________._____), lawful money of the United States, to be paid to
the Missouri Division of Employment Security, for which sums of money, well and truly to be paid, we bind ourselves, our heirs,
successors, assigns, executors, and administrators, jointly and severally, firmly by these presents.
THE CONDITION OF THE FOREGOING OBLIGATION IS SUCH THAT,
Whereas, under Section 288.032.2 of the Missouri Employment Security Law, Chapter 288 RSMo, a lessor employing unit
may post a bond of an amount as specified therein to insure timely payment of contributions, payments in lieu of contributions,
interest, penalties, and surcharges for which the lessor employing unit may be, or become, liable under the Employment Security
Law; and,
Whereas, not later than the end of February of each calendar year hereafter, the specified amount of the bond will be adjusted
if necessary; and,
Whereas, said bond shall be deposited with the Director of the Missouri Division of Employment Security and maintained for
safekeeping by said Director; and,
Whereas, the following lessor employing unit wishes to post with the Director of the Missouri Division of Employment
Security a Surety Bond:
NAME OF LESSOR EMPLOYING UNIT _________________________________________________________________
BUSINESS ADDRESS _________________________________________________________________________________
MAILING ADDRESS __________________________________________________________________________________
FEDERAL IDENTIFICATION NUMBER __________________________________________________________________
MO. DES ACCOUNT NUMBER _________________________________________________________________________
MODES-4252 (08-06) AI
Legal
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