Form Cg-106 - Wholesale Cigarette Dealer'S Bond Form - Kansas Department Of Revenue

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KANSAS DEPARTMENT OF REVENUE
MISCELLANEOUS TAX – CUSTOMER RELATIONS
915 SW HARRISON ST.
TOPEKA, KANSAS 66612-1588
Website:
Email: miscellaneous.tax@kdor.ks.gov
Bond No. _______________
Phone: (785) 368-8222
Fax: (785) 296-4993
(Affix Bond No. on Document)
WHOLESALE CIGARETTE DEALER’S BOND
KNOW ALL MEN BY THESE PRESENTS: THAT________________________________________________________________ with main
(Principal)
office location at ________________________________________________________________________________________ as Principal, and
(Street Address)
(City)
(State & Zip Code)
the __________________________________________________________________________________________ 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 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, as individually set out below in the following schedule:
S Wholesale Cigarette Dealer’s License
$ ____________________
S Wholesale Cigarette Dealer’s Tax Credit
$ ____________________
WHEREAS, The above-named principal, a LICENSED WHOLESALE CIGARETTE DEALER within the provisions of Chapter 79, Article 33,
G.S., Kansas, 1949, and amendments thereto, is authorized to affix cigarette tax stamps or Kansas tax indicia to packages of cigarettes at his/their
licensed location at:
_________________________________________________ ________________________ ________________________________
(Street Address)
(City)
(State & Zip Code)
and is required by such law to comply with all the provisions of said law together with the Sales and Compensating Tax 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
Cigarette Tax Law. The forfeiture of any Wholesale Dealer’s Bond shall be in an amount only to the extent of moneys due and 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
Chapter 79, Article 33, G.S., Kansas, 1949, and amendments thereto, together with the Sales and Compensating Tax 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 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 ______________________________________, ____________.
(Year)
Witness our hands at ______________________________, Kansas, this _________________ day of ____________________________, ___________
(Year)
_________________________________________________
(Principal)
By ___________________________________________________
(Indicate Position: President, Vice-President, Partner, Owner)
Attest _____________________________________________
_________________________________________________
(Second Corporate Officer, Indicate Office)
(Surety)
_________________________________________________
(Surety Address)
______________________________________________________
SEAL
(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.
Countersigned at ________________________________________, Kansas by ______________________________________________________
(Kansas Licensed Agent)
CG-106
(Rev. 2-16)

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