Form Mf-135 (State Form 46844) - Gasoline/special Fuel Irrevocable Standby Letter Of Credit 2004
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2STATE OF INDIANA
MF-135
DEPARTMENT OF REVENUE
State Form 46844
(R1/8-04)
____________________________________
____________________________________
Applicant's Name
Applicant's License Account Number
Gasoline/Special Fuel
Irrevocable Standby Letter Of Credit #
___________________________________________
___________________________________________
Issuing Bank Name
Address
___________________________________________
(______) ___________________________________
Bank FEIN#
Phone Number
___________________________________________
___________________________________________
Effective Date
Expiration Date
We, _________________________________________ , hereby issue an IRREVOCABLE STANDBY LETTER OF CREDIT for the
Issuing Bank
name of ______________________________________________________________________________________ , in the amount
Applicant's Name and Address
of $ _______________________ (________________________________________ Thousand and no/100 Dollars) which is available
by the Indiana Department of Revenue draft drawn at sight of __________________________________________ bearing the clause
Issuing Bank Name
"drawn under ___________________________________________ Letter Credit for _______________________________________"
Issuing Bank Name
Applicant's Name
accompanied by this Letter of Credit and the following:
Statement purportedly signed by an officer of the Indiana Department of Revenue certifying that
___________________________________________ has been served a pre-warrant notice covering nonpayment
of ____________________ taxes pursuant to ____________________ plus all applicable penalties and interest due the Indiana
Type of Tax
Indiana Code Reference
Department of Revenue and has failed to provide an acceptable explanation within the time period for such protests or payment of tax.
A copy of the pre-warrant notice which bears the expiration date of at least five (5) days prior to the date of the draft.
Drawings may be made up to an aggregate amount but not to exceed ___________________________________________.
Amount of Letter of Credit
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