Form Rpd-41107 - Special Fuel Supplier/gasoline Distributor Tax Bond - 1997 Page 2

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ACKNOWLEDGMENT OF PRINCIPAL
(IF A CORPORATION)
STATE OF ____________________________
COUNTY OF __________________________
SUBSCRIBED AND SWORN TO before me this
day of
, 19
.
ACKNOWLEDGMENT OF PRINCIPAL
(IF AN INDIVIDUAL OR PARTNERSHIP)
STATE OF ____________________________
COUNTY OF __________________________
SUBSCRIBED AND SWORN TO before me this
day of
, 19
.
ACKNOWLEDGMENT OF SURETY
STATE OF ____________________________
COUNTY OF __________________________
SUBSCRIBED AND SWORN TO before me this
day of
, 19
.
*Copy of Power of Attorney must accompany bond if signed by Attorney-in-Fact.

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