Form Ador 74-4058 - Security In Lieu Of Cash Deposit For Compliance With Arizona Revised Statutes
Download a blank fillable Form Ador 74-4058 - Security In Lieu Of Cash Deposit For Compliance With Arizona Revised Statutes in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Ador 74-4058 - Security In Lieu Of Cash Deposit For Compliance With Arizona Revised Statutes with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Assignment to Arizona Department of Revenue
Assignment to Arizona Department of Revenue
Security in Lieu of Cash Deposit for Compliance with
Security in Lieu of Cash Deposit for Compliance with
Arizona Revised Statutes
Arizona Revised Statutes
Section:
Section:
42-1102
42-1102
42-5006
42-5006
42-5007
42-5007
Name
Street Address
County
State
Telephone Number
hereinafter referred to as ASSIGNOR, does hereby assign and transfer to the Department of Revenue of the State of Arizona, hereinafter
referred to as the Department of Revenue, all right, title and interest of any kind whatsoever, owned or held by Assignor in the principal,
but not in the interest hereinafter accruing, in the insured account of ASSIGNOR
Financial Institution
Whose Address
Street Address
City
Arizona, as evidenced by an account in the amount of
dollars
($
), identifi ed by account number
which account is
insured by the Federal Deposit Insurance Corporation or the Federal Savings and Loan Insurance Corporation. Assignor states that the
assignor has an unimpaired ownership of or right to the proceeds in the aforementioned account. This assignment is given as security
for Arizona tax liability incurred while operating a licensed business and to insure full compliance with the above identifi ed statute.
Dated this
day of
, 20
, at
, Arizona
Name and Title
By:
Signature of Assignor
First Endorsement - Receipt for Notice of Assignment
Receipt is hereby acknowledged to the Department of Revenue of the State of Arizona, hereinafter referred to as the Department of
Revenue, of written notice of the assignment to said Department of Revenue of the above-identifi ed account. We have noted our
records to show the interest of the Department of Revenue in said account as shown in and by the assignment above. We have retained
a copy of this document. We hereby certify that we have not received nor will we honor any future notice of lien, encumbrance,
hold claim or other obligation against the above-identifi ed account prior to its assignment to the Department of Revenue. We futher
hereby waive any current and future right of set-off against such account. We agree to make payment as required by the Department
of Revenue in accordance with applicable laws.
Dated this
day of
, 20
, at
, Arizona
Name of Financial Institution
By:
Signature of Offi cer of Financial Institution
Subscribed and sworn to before me this
day of
, 20
Notary Public
Second Endorsement - Receipt for Security and Direction to Pay Earnings
Receipt is acknowledged of the assignment above and the account identifi ed in the assignment above. The fi nancial institution named
in the assignment above is hereby authorized and directed to pay any earnings on the above-identifi ed account to the above-name
assignor.
Dated this
day of
, 20
, at
, Arizona
Arizona Department of Revenue
Director or authorized representative
By:
Title:
PLEASE COMPLETE ALL INFORMATION
Mail Original Document To: Arizona Department of Revenue, Bond Offi cer, 1600 W. Monroe, Phoenix, AZ 85007.
ADOR 74-4058 (6/07)
Print
Reset form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ador 74-4058 - Assignment To Arizona Department Of Revenue Security In Lieu Of Cash Deposit For Compliance With Arizona Revised Statutes
Financial
Security In Lieu Of Performance Bond Form - Assignment To Flood Control District Of Maricopa County State Of Arizona
Business
Related Categories
Parent category: Financial