Form 2789 - Motor Fuel Tax Cash Bond - Missouri Department Of Revenue 2006
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MISSOURI DEPARTMENT OF REVENUE
FORM
TAXATION BUREAU
P.O. BOX 300
2789
JEFFERSON CITY, MISSOURI 65105-0300
(573) 751-2611
TDD 1-800-735-2966
(REV. 11-2006)
MOTOR FUEL TAX CASH BOND
KNOW ALL MEN BY THESE PRESENTS:
That I
NAME OF INDIVIDUAL OR COMPANY
Please check appropriate box:
licensed as a Missouri
Supplier
Permissive Supplier
Distributor
Transporter
Terminal Operator
of
County, State of
as principal, am held and firmly bound unto the Department of Revenue of the State of Missouri, hereinafter known as the
obligee, in the sum of
DOLLARS
($
), lawful money of the United States as evidenced by the attached CASHIER’S
CHECK or MONEY ORDER, which shall be in the safekeeping of the obligee.
THE CONDITIONS OF THE FOREGOING OBLIGATION IS SUCH THAT,
The principal has applied for, or has obtained, a fuel license and will be subject to the Missouri Motor Fuel Tax Law and all
amendments lawfully made.
If the principal has complied with all the provisions of the law and any amendments, and, in particular, has paid all taxes, fees,
interest and penalties due and owing, then the Director of Revenue, upon request of the taxpayer, at the discontinuance of the
licensing requirements, or upon receipt of alternative bonding, will refund the amount to the taxpayer. If the taxes, fees, interest
and penalties due and owing are not paid in full, the taxpayer will forfeit the amount of bond to satisfy the outstanding liability.
SIGNATURE OF PRINCIPAL
BY (NAME AND TITLE)
NOTARY PUBLIC
IN TESTIMONY WHEREOF, I have thereunto set my hand and affixed the official seal at my office.
NOTARY PUBLIC EMBOSSER SEAL
STATE
COUNTY (OR CITY OF ST. LOUIS)
USE RUBBER STAMP IN CLEAR AREA BELOW.
SUBSCRIBED AND SWORN BEFORE ME, THIS
DAY OF
NOTARY PUBLIC SIGNATURE
MY COMMISSION
EXPIRES
NOTARY PUBLIC NAME (TYPED OR PRINTED)
This publication is available upon request in alternative accessible format(s).
MO 860-0168 (11-2006)
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