Form Tb-85 - Tobacco Products Distributor'S Tax Bond Form - Kansas Department Of Revenue

KANSAS DEPARTMENT OF REVENUE

MISCELLANEOUS TAX

915 SW HARRISON ST.

TOPEKA, KANSAS 66612-1588

Bond No.:

_________________

Website:

Email: miscellaneous.tax@kdor.ks.gov

(Bond will not be accepted without

Phone: (785) 368-8222

Fax: (785) 296-4993

number)

TOBACCO PRODUCTS DISTRIBUTOR’S TAX BOND

KNOW ALL MEN BY THESE PRESENTS: THAT

__________________________________________________________________

with main

(Principal)

office location at _______________________________________________________________________________________

as Principal, and the

(Street Address)

(City)

(State & Zip Code)

_______________________________________________________________________________________________

a corporation authorized to

(Surety Company Name)

transact business in Kansas, as surety, are held and firmly bound unto the STATE OF KANSAS in the penalty sum of

___________________________ thousand dollars ($______________________), lawful money of the United States, to the payment of which, well

thousand dollars

and truly to be made, we hereby bind ourselves, our heirs, executors, administrators, assigns and successors firmly by these presents.

Whereas, the above-named principal, a LICENSED DISTRIBUTOR OF TOBACCO PRODUCTS within the provisions of K.S.A. 79-3374, is

authorized to distribute tobacco products at its licensed location at:

_________________________________________________________________________________________________________________________

(Street Address)

(City)

(State)

and is required by such law to comply with all the provisions of said law together with the rules and regulations pursuant thereto, as adopted by the

Director of Taxation and to make such reports and furnish such information as the Director of Taxation may require, to said Director at his office in

Topeka, Kansas; and to further pay all taxes due and owing the State of Kansas as provided in said Kansas Tobacco Products Law. The forfeiture of

any Distributor’s Bond shall be in an amount equal to all such taxes, penalty and interest owing the State of Kansas.

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

K.S.A. 79-3374, together with the rules and regulations promulgated by the Director of Taxation pursuant thereto, 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 a statement of account relating to the tax guaranteed by this bond.

This bond is effective on and after the

_______________ day of ______________________________________, ____________.

day of

(Year)

Witness our hands at

Witness our hands at ______________________________, Kansas, this _________________ day of __________________________, _________

, Kansas, this

day of

(Year)

______________________________________________________

(Principal)

By

____________________________________________________

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

______________________________________________________

(Surety)

______________________________________________________

SEAL

(Surety Address)

______________________________________________________

(Surety Company Phone Number)

By

____________________________________________________

(Surety Signature)

Its

____________________________________________________

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

Kansas licensed agent of the surety must countersign.)

(Extract from K.A.R. 92-17-5)

Any surety on a bond furnished by a tobacco products distributor as provided herein shall be released and discharged from any and all liability to the state accruing

on such bond after the expiration of sixty 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-day period.

TB-85

(Rev. 2-16)