Form Rt 133 - Motor Fuel Distributor Bond Page 2
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2STATE OF NEW HAMPSHIRE
DEPARTMENT OF SAFETY
ROAD TOLL BUREAU
33 HAZEN DRIVE, CONCORD NH 03305
TELEPHONE: (603)271-2311
RELEASE AND DISCHARGE OF SURETY LIABILITY SHALL BE IN ACCORDANCE WITH RSA 260:37, II.
IN TESTIMONY WHEREOF, THE PRINCIPAL HAS HERE UNTO SET HIS HAND AND SEAL AND THE SURETY HAS CAUSED THIS
INSTRUMENT TO BE SIGNED BY______________________________AND ITS CORPORATE SEAL TO BE HEREUNTO AFFIXED THE DAY
AND YEAR FIRST ABOVE WRITTEN.
WITNESS:
WITNESS NAME
PRINCIPAL SIGNATURE
(SEAL)
WITNESS SIGNATURE
PRINCIPAL TITLE
COMPANY
COUNTERSIGNED,
NH LICENSED AGENT NAME
NH LICENSED AGENT ATTORNEY SIGNATURE
(SEAL)
NH LICENSED AGENT SIGNATURE
NH LICENSED AGENT ATTORNEY NAME
NH LICENSED AGENT ATTORNEY TITLE
FOR OFFICIAL USE ONLY
APPROVAL DATES
SECRETARY OF STATE
INSURANCE COMMISSIONER
BOND DETAILS
BOND AMOUNT:
BOND TYPE:
BOND NUMBER:
EFFECTIVE DATE:
CANCEL DATE:
RT 133 (Revised 03/2010)
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