Form 04-409 - Motor Fuel Excise Tax - Qualified Dealer Bond
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Motor Fuel Excise Tax
Alaska Department of Revenue
Voice: 907.269.6620
QUALIFIED DEALER BOND
Tax Division
Fax: 907.269.6644
43.40.100
550 W. 7th Avenue suite 500
Email: Tax_Motor_Fuel@revenue.state.ak.us
Anchorage, AK 99501
Corporation/Principal Name
Bond Number
Phone
Corporation/Principal Address
City
State
Zip
Business Type (check one):
Corporation
Partnership
Sole proprietor
LLC
We, as principal(s), and ______________________________________________________________ as surety
(Name of Insurance Company)
a corporation incorporated under the laws of the State of _______________________________________
and authorized to do business in the State of Alaska and execute this bond, are held and firmly bound unto
the State of Alaska, Department of Revenue, in the sum of $___________________________, the payment
of which we bind ourselves, our executors, administrators, heirs, assigns, and successors, jointly and
severally, firmly by this bond.
The condition of the foregoing obligation is that the above bound principal(s) shall pay when due all motor fuel
excise fees and/or taxes, penalties and interest due and to become due and owing to the State of Alaska by
said principal during the effective period of the bond, under the provisions of the motor fuel excise tax and
licensing laws of the State of Alaska (AS 43.40).
Liability under this bond begins _____________________________ and shall be continuous thereafter until
(Date)
statute of limitations has expired on all motor fuel excise taxes due to the State of Alaska. The bond shall
apply to all liens and liabilities which arise during the effective period of the bond and to which the bond is
applicable under law, even if the liens are foreclosed or valid liens settled after the period of the bond or the
liabilities are enforced after the effective period of the bond.
In witness whereof, the above bound parties have executed this instrument this _______________ day of
________________________, 20_____ the name of each party being hereto affixed and is duly signed by its
undersigned representative, if any, pursuant to authority of its governing body.
ATTEST:
By:
(Secretary of Corporation/Principal)
(Authorized Agent of Corporation/Principal)
(seal)
ATTEST:
By:
(Secretary of Insurance Company)
(Authorized Agent of Insurance Company)
Form 04-409 Webform (Rev 03/03)
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