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Form 72-441-05-1-1-000 (Rev. 11/05)

STATE TAX COMMISSION

Bond Number______________

JACKSON, MISSISSIPPI

CONTRACTOR'S JOB SALES, USE, INCOME, FRANCHISE,

WITHHOLDING, AND SPECIAL FUEL (DIESEL FUEL) TAX BOND

KNOW ALL MEN BY THESE PRESENTS, That______________________________________________________________________

(Name and Address)

__________________________________________________________________________________________________ as Principal,

and ________________________________________________________________________________________________ as Surety,

(Name and Address)

are held and firmly bound unto the State of Mississippi for the payment when due of all taxes, damages, interest and penalties which may

accrue to the State of Mississippi under Section 27-65-1 et seq., and Section 27-67-1 et seq., and Section 27-7-1 et seq., and Setion

27-13-1 et seq., and Section 27-7-301 et seq., and Section 27-55-313, Mississippi Code of 1972, and amendments thereto, for the

payment of which taxes, damages, interest and penalties well and truly to be made, we bind ourselves, our heirs, executors,

administrators, successors, and assigns jointly and severally by these persents.

WHEREAS, The said Principal has entered into a certain contract, described as follows, to wit:

____________________________________________________________________________________________________________

WHEREAS, under the provisions of Section 27-65-21, Mississippi Code of 1972, as amended, the said Principal is required

to and has furnished this bond guaranteeing payment when due of all taxes, damages, interest and penalties which may

accrue to the State of Mississippi under Section 27-65-1 et seq., and Section 27-67-1 et seq., and Section 27-7-1 et seq.,

and Section 27-13-1 et seq., and Section 27-7-301 et seq., and Section 27-55-313, Mississippi Code of 1972, and

amendments thereto, on account of entering into said contract.

NOW, THEREFORE, THE CONDITION OF THIS OBLIGATION IS SUCH THAT, if the said Principal shall promptly pay when

due all taxes, damages, interest and penalties which may accrue to the State of Mississippi under Section 27-65-1 et seq.,

and Section 27-67-1 et seq., and Section 27-7-1 et seq., and Section 27-13-1 et seq., and Section 27-7-301 et seq., and

Section 27-55-313, Mississippi Code of 1972, and amendments thereto, on account of the execution of the aforesaid

contract, then this obligation is void; otherwise it shall remain in full force and effect.

Notwithstanding the tax information and return confidentiality provisions contained within Sections 27-65-1 et seq., 27-67-1

et seq., 27-7-1 et seq., 27-13-1 et seq., 27-7-301 et seq., and 27-55-301 et seq, Mississippi Code of 1972, and amendments

thereto, principal hereby authorizes the State Tax Commission to release to surety any information relating to any claim

against said surety made by the State Tax Commission which is covered by this bond.

SIGNED, SEALED AND DELIVERED, This the _________ day of _________________________________, 20 ________

Filed and Approved this the _____________________ day

of ____________________________________, 20______.

_____________________________________________

Principal

_______________________________________________

By___________________________________________

Commissioner and Chairman of the STATE TAX COMMISSION

Surety

COUNTERSIGNATURE:

By ___________________________________________

Attorney in Fact

(SEAL)

______________________________________________

Licensed Mississippi Agent

______________________________________________

(Type or Print Name of Agent)

______________________________________________

(Telephone Number)

Form 72-441-05-1-1-000 - Contractor'S Job Sales, Use, Income, Franchise, Withholding, And Special Fuel (Diesel Fuel) Tax Bond

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