Form 04-041d - Cigarette Licensee Surety Bond

Alaska Department of Revenue

Tax Division

550 W. 7

Avenue, Suite 500

Anchorage, AK 99501

Cigarette Licensee Surety Bond

AS 43.50.550

Principal Name _______________________________ Bond Number______________________

Principal Address _____________________________

_____________________________

Business Type (check one):

Corporation

Partnership

Sole proprietor

LLC

Other________________

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, execute this bond and 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

cigarette fees and/or taxes, penalties and interest due and to become due and owing to the State of

Alaska by said principal during the fiscal year beginning July 1, ________ and ending June 30,

________, under the provisions of the cigarette tax and licensing laws of the State of Alaska (AS

43.50).

This bond may not be cancelled and, furthermore, the liability herein assumed shall continue until the

statute of limitations has expired on all cigarette excise taxes due to the State of Alaska of said principal

for the fiscal year indicated above.

In witness whereof, the above bound parties have executed this instrument this _________ day of

______________, 20____ the name and seal of each party being hereto affixed and is duly signed by its

undersigned representative, if any, pursuant to authority of its governing body.

____________________________________

(seal)

(Principal)

ATTEST:

____________________________________

By: ________________________________

(Secretary of Principal)

(Authorized Agent)

___________________________________

(seal)

(Surety)

ATTEST:

____________________________________

By: ________________________________

(Secretary of Surety)

(Authorized Agent)

Form 04-041D (Rev 10/03) webform

Form 04-041d - Cigarette Licensee Surety Bond - 2003

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