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Form 72-441-14

Sales Tax Account ID:

MISSISSIPPI DEPARTMENT OF REVENUE

_ _ _ _ - _ _ _ _

P.O. BOX 1033

JACKSON, MS 39215

CONTRACTOR’S JOB SALES, USE, INCOME, FRANCHISE, WITHHOLDING AND

SPECIAL FUEL (DIESEL FUEL) TAX BOND

STATE OF MISSISSIPPI

BOND NUMBER _____________________

KNOW ALL MEN BY THESE PRESENTS, THAT ___________________________________________________________

Owner of Business

_________________________________________________________________________________________________________

Trading As

Address

City

State

Zip

As Principal, and _____________________________________________________________, as Surety, are held and firmly bound

unto the State of Mississippi for the payment of when due of all taxes, damages, interest and penalties which may accrue to the State

of Mississippi under Miss Code Ann. § 27-65-1 et seq., and § 27-67-1 et seq., and § 27-7-1 et seq., and § 27-13-1 et seq., and §

27-7-301 et seq., and § 27-55-313 et seq., amendments thereto, for the payment of which taxes, damages, interest and penalties well

and truly to be made, we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, by these

presents.

WHEREAS, The said Principal has entered into a certain contract, described as follows, to wit:

_________________________________________________________________________________________________________

WHEREAS, under the provisions of Miss. Code Ann. § 27-65-21, as amended, the said Principal is required to and has furnished this

bond guaranteeing payment when due of all taxes, damages, interest and penalties which may accrue to the State of Mississippi

under Miss. Code Ann. § 27-65-1 et seq., and § 27-67-1 et seq., and § 27-7-1 et seq., and § 27-13-1 et seq., and § 27-7-301 et seq.,

and § 27-55-313 et seq., amendments thereto, on account of entering into said contract.

NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH THAT, if the said Principal shall promptly pay when due all

taxes, damages, interest and penalties which may accrue to the State of Mississippi under Miss. Code Ann. § 27-65-1 et seq., and §

27-67-1 et seq., and § 27-7-1 et seq., and § 27-13-1 et seq., and § 27-7-301 et seq., and § 27-55-313 et seq., amendments thereto,

on account of the execution of the aforesaid contract, then this obligation is void; otherwise it shall remain in full force and effect.

NOTWITHSTANDING the tax information and return confidentiality provisions contained within Miss Code Ann. § 27-65-1 et seq., §

27-67-1 et seq., 27-7-1 et seq., 27-13-1 et seq., 27-7-301 et seq., and 27-55-301 et seq., and to any claim against said surety made

by the Department of Revenue which is covered by this bond.

SIGNED, SEALED AND DELIVERED, this ________ day of _______________, 20____.

Filed and Approved, this _______________day of ____________________________, 20______.

COMMISSIONER: ______________________________________ PRINCIPAL: ________________________________________

Countersigned by:

____________________________________________________ SURETY:

_________________________________________

Attorney in Fact

___________________________________________________________________

______________________________________________________

Licensed Mississippi Agent

__________________________________________________________________

Type or Print Name of Agent

Telephone Number

Form 72-441-14 - Contractor'S Job Sales, Use, Income, Franchise, Withholding Tax Bond 2014

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