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Form Mf-134 - Gasoline / Special Fuel Cash Bond - State Of Indiana Department Of Revenue

STATE OF INDIANA

DEPARTMENT OF REVENUE

MF-134

(4/03)

State Form 46843

Gasoline

Cash Bond Number

Applicant's Money Held in Escrow

Special Fuel

Applicant's Money Held in Escrow

_________________________________

License Number

GASOLINE / SPECIAL FUEL CASH BOND

KNOW ALL MEN BY THESE PRESENTS:

Cash bond given by

(Name of Principal - Surety)

to the State of

(Street Address, City, County, State, Zip Code)

Indiana in the sum of

Dollars, for the payment of

which we bind ourselves, our heirs, executors, administrators and assigns.

The above Principal-Surety,

(Name of Principal - Surety)

has applied for, and, subject to the approval of this cash bond as provided by law, has obtained a

gasoline and/or special fuel license(s) to engage in business as defined by both Indiana Code

6-6-1.1 et. seq. and Indiana Code 6-6-2.5 et. seq. all related acts and regulations. Thus, if the

Principal - Surety becomes duly licensed and does comply with all provisions of Indiana Code

6-6-1.1et. seq. and Indiana Code 6-6-2.5 et. seq and all related acts and regulations and does satisfy

all taxes, penalties, and forfeitures prescribed pursuant to Indiana Code 6-6-1.1 and Indiana Code 6-

6-2.5 et. seq. , and all related acts and regulations, then this obligation shall be null and void; other-

wise, it shall be and remain in full force and effect.

This instrument is in full force and effect from its effective date,

, and shall not expire until cancelled as provided by this instrument. Cancellation may be

effected by any party to this instrument by giving the other parties sixty (60) days written notice, as

provided by law. Notice of cancellation shall not affect liabilities of the Principal - Surety for its own

acts or omissions prior to the effective date of the cancellation. This bond shall remain in full force and

effect for all liabilities which occurred before and including the effective date of the cancellation and

for a period of three (3) years and one (1) day after the expiration of the bond as provided by this

instrument, unless written notice is issued by the Administrator to the effect that all obligations due the

State of Indiana have been paid.

Form Mf-134 - Gasoline / Special Fuel Cash Bond - State Of Indiana Department Of Revenue