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72A004 (8-06)

Bond Number ____________________

MOTOR FUELS TAX

Commonwealth of Kentucky

WATERCRAFT REFUND BOND

DEPARTMENT OF REVENUE

Effective Date ____________________

KNOW ALL MEN BY THESE PRESENTS, that we, ________________________________________________________ ,

Name of principal

________________________________________________________________________________________________________ ,

Street or P. O. Box

City

State and ZIP Code

as principal, and _________________________________________________ of _______________________________________ ,

Name of Surety

Address of Surety

as surety, are held and firmly bound unto the Commonwealth of Kentucky in the sum of $1,000, for the prompt and faithful compliance

with the provisions of Kentucky Revised Statute 138.445, we bind ourselves, our heirs, executors, administrators, successors and

assigns, jointly and severally, firmly by these presents.

The condition of this obligation is such that, whereas, the Principal is now engaged in, or is about to engage in, the sale of

liquid fuel for the operation of watercraft, and in such operation is entitled to a refund of the tax paid on liquid fuel purchased by a

public boat dock operator or other dispensing facility which floats upon the water to be sold for use in the operation of watercraft, and

whereas, the Principal from time to time will be making applications to the Commonwealth of Kentucky for refund of taxes paid on

liquid fuel used in watercraft.

NOW THEREFORE, the condition of this obligation is such that, if the Principal shall faithfully comply with the provisions of

the aforementioned Kentucky Revised Statue 138.445 and repay to the Commonwealth of Kentucky any refunds to which it is not

entitled, then this obligation shall be void, otherwise it shall remain in full force and effect. Provided, however, this bond can be

terminated by the surety upon written notice to the department and Principal given by registered mail 60 days in advance.

IN WITNESS WHEREOF, we have hereunto set our hands this ___________________ day of ____________ , 20 ______ .

By ______________________________________________

Owner or President

_________________________________________________

By ______________________________________________

Surety

Attorney-in-Fact

________________________________________________

and/or Kentucky Resident Agent of Surety Company

________________________________________________

Address of Kentucky Resident Agent

Return to Department of Revenue, Motor Fuels Tax Compliance Section, Frankfort, Kentucky 40620.

DO NOT COMPLETE—FOR DEPARTMENT USE ONLY

Initials

Date

Reviewed _____________

______________

_____________

______________

Form 72a004 - Motor Fuels Tax Watercraft Refund Bond - Kentucky Department Of Revenue

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