Fillable Form Ft 462 - Fuels Tax Bond (Page 2 of 2) in pdf

ACKNOWLEDGMENT OF PRINCIPAL

FT 462 (10/10/2013)

Page 2

STATE OF ________________________________________________

_____________________________________________________________ of _____________________________________________________, to-wit:

I, _____________________________________________________________________________________________________________, a notary public

in and for the ___________________________________________ aforesaid, in the State of ______________________________ , do certify that on the

________________ day of __________________________________ , ___________ , before me personally came, in my___________________________

(Year)

aforesaid ____________________________________________________________________________________________________________________

who, being by me duly sworn, did depose and say that he resides in _____________________________________________________________________

that he is the ____________________________________________ of ___________________________________________________________________

(Title)

(Name of Company)

the ________________________________________ described in and which executed the above instrument as PRINCIPAL; that he

(Type of Company)

knows the seal of said company; that the seal affixed to said instrument is such company seal; that it was so affixed by order of and with the authority to

act on behalf of the said company, and that he signed his name thereto by like order.

I further certify that my term of office expires on the ______ day of _____________________, _______. My Registration Number is ___________________.

(six digits)

(Year)

Given under my hand this _________________ day of ____________________________________________________________ , _______________

(Year)

___________________________________________________________

(Notary Public Signature/Seal)

AFFIDAVIT AND ACKNOWLEDGMENT OF SURETY

STATE OF _______________________________________________

______________________________________________________________ of ___________________________________________________ , to-wit:

I, _____________________________________________________

, a notary public in and for the ___________________________________________

aforesaid, in the State aforesaid, do certify that _____________________________________________________________________________________

personally appeared before me in my _________________________________________________________________ aforesaid and made oath that he is

______________________________________________________________ of the _______________________________________________________

that he is duly authorized to execute the foregoing bond by virtue of a certain power of attorney of said company, dated

________________________________________, and recorded in the Clerk's office of the _________________________________________________ of

___________________________________________________, in Deed Book No. _________________________________, page __________________;

that said power of attorney has not been revoked; that the said company has complied with all the requirements of law regulating the admission of such

companies to transact business in the State of Virginia; that the said company holds a license of the State Corporation Commission authorizing it to do

business in the State of Virginia; that its surplus to policyholders is $ _______________________________________________; that the penalty of the

This blank must be properly filled out

foregoing bond is not in excess of ten per centum of said sum; that th

ate, on behalf or on account of

e said company is not by said bond incurring in the aggreg

the principal named in said bond, a liability for an amount larger than one-tenth of its surplus to policyholders; that the said company is neither directly nor

indirectly under the same ownership or management as the principal in this bond; that the said company is solvent and fully able to meet promptly all of its

obligations, and the said ___________________________________________________________________________ thereupon, in the name and on

behalf of the said company, acknowledged the foregoing writing as its act and deed.

My term of office expires _______________________________________________, ____________. My Registration Number is ___________________.

(six digits)

(Year)

Given under my hand this _________________________ day of _____________________________________________________, _______________

(Year)

__________________________________________________________

(Notary Public Signature and Seal)