Form Mf-27 - Motor Vehicle Fuel And Special Fuel Distributor'S Bond

KANSAS DEPARTMENT OF REVENUE

BOND NO. _________________

CUSTOMER RELATIONS

(Affix Bond No. on Document)

915 SW HARRISON ST.

TOPEKA, KANSAS 66625-8000

Phone Number: (785) 368-8222

Fax: (785) 296-4993

MOTOR VEHICLE FUEL AND SPECIAL FUEL DISTRIBUTOR’S BOND

KNOW ALL MEN BY THESE PRESENT: THAT

(Underline one - Individual Proprietorship, Partnership, or Corporation)

with main office location at

(Street Address)

(City)

(State & Zip Code)

as Principal, and the

(Surety Company Name)

a corporation authorized to transact business in Kansas, as surety, are held and firmly bound unto the STATE OF

KANSAS in the sum of

dollars ($

lawful money of the United States, to the payment of which, well and truly to be made, we hereby bind ourselves, our

heirs, executors, administrators, assigns, and successors firmly by these present.

WHEREAS, The above-named principal is a distributor within the provisions of the motor fuel tax laws of the state

of Kansas, and is required by such law to render certain sworn statements and reports and pay certain motor fuel taxes,

interest and penalties, all to the Director of Taxation, Kansas Department of Revenue, Topeka, Kansas, and to otherwise

comply with the provisions of said laws:

NOW, THEREFORE, The condition of this obligation is such that if the above-named principal shall faithfully

comply with all the provisions of said motor fuel tax laws of the state of Kansas, then this obligation shall be void and of

no effect; otherwise it shall be and remain in full force and effect. Said principal hereby authorizes employees of the

Kansas Department of Revenue to disclose to the surety herein all matters relating to the tax guaranteed by this bond.

This bond is effective on and after the

day of

, 20

Witness our hands at

, Kansas, this

day of

(Indicate Position: President, Vice-President, Partner, Owner)

(Surety)

(Surety Street Address)

(City)

(State & Zip Code)

(Surety Company Phone Number)

(Surety Signature)

Its

(Bond shall be accompanied by power of attorney for attorney-in-fact.)

(EXTRACT FROM MOTOR FUEL TAX LAW)

The surety on this bond shall be released and discharged from any and all liability to the state of Kansas, accruing on such bond after

the expiration of sixty (60) days from the date upon which such surety shall have lodged with the director a written request to be

released and discharged, but this provision shall not operate to relieve, release or discharge the surety from any liability already

accrued, or which shall accrue, before the expiration of the sixty (60) day period.

MF-27

(Rev. 4/04)

Form Mf-27 - Motor Vehicle Fuel And Special Fuel Distributor'S Bond - 2004

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