Fillable Form Modes-4252 - Surety Bond (Page 2 of 3) in pdf

NAME(S), ADDRESS AND SOCIAL SECURITY NUMBER OF OWNERS,

PARTNERS OR CORPORATE OFFICIALS:

(1)_______________________________________________________________________________________________________

(2)_______________________________________________________________________________________________________

(3)_______________________________________________________________________________________________________

(4)_______________________________________________________________________________________________________

(5)_______________________________________________________________________________________________________

NOW THEREFORE, if said principal shall well and truly comply with all the provisions of the Missouri Employment Security

Law, Chapter 288 RSMo, and any amendments thereto, and in particular pay all contributions, interest and penalties promptly when

due, then this obligation shall be null and void; otherwise, it shall remain in full force and effect.

If said principal is delinquent, the Missouri Division of Employment Security will notify said surety. Surety then has thirty

(30) days in which to make payment or contact the Missouri Division of Employment Security stating reasons payment has not been

made.

The said principal authorizes the release of the confidential tax information to said surety as long as this obligation remains in

force and effect; releasing the Director of the Missouri Division of Employment Security and Division personnel from any and all

liability pursuant to any disclosures to said surety of confidential tax information resulting from release of subject information.

This obligation shall remain in force and effective for a period of not less than five (5) years from the initial date of bonding

or until the Director of the Missouri Division of Employment Security releases said principal from the bonding requirement as set

forth by Section 288.032.2 RSMo and supplement thereto. The surety may cancel the bond and be released of further liability

hereunder by delivering sixty (60) days written notice to the principal and to the Director of the Missouri Division of Employment

Security. Such cancellation shall not affect any liability incurred or accrued hereunder prior to the termination of the sixty (60) day

period.

IN WITNESS WHEREOF, we have duly executed the foregoing obligation this ____________________________________

day of ___________________________ A.D. 20____. To be effective on the __________________________________________

day of ___________________________ A.D. 20____.

Surety Company Name

ATTEST:

(Insurance Companiy Seal)

Signature of Attorney-In-Fact

Surety’s Street Address or P.O. Box

City, State, Zip Code

Signature of Owner, Partner or Corporate Officer of Business

MODES-4252-2 (08-06) AI

Form Modes-4252 - Surety Bond Page 2