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Form 72-442-05-1-1-000 (Rev. 11/05)

STATE TAX COMMISSION

Bond Number______________

JACKSON, MISSISSIPPI

CONTRACTOR'S BLANKET 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, in the just and full sum of ($______________________________),

____________________________________________________________________________Dollars, for the payment of

which sum well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors, and assigns jointly

and severally by these presents.

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 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 any contract as defined in said statutes.

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

____________________day of _________________________________________________________, 20_______to the

____________________day of _________________________________________________,20________ pay when due

all taxes, damages, interest and penalties which may accrue during that time 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, 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.

PROVIDED, HOWEVER, that no new liability shall accrue under this bond thirty days after receipt by the Obligee of written

notice from the Surety of its desire to cancel this bond.

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

Filed and Approved this the _____________________ day

of ____________________________________, 20______.

_____________________________________________

Principal

_____________________________________________

Surety

_______________________________________________

By___________________________________________

Commissioner and Chairman of the STATE TAX COMMISSION

Attorney in Fact

COUNTERSIGNATURE:

By ___________________________________________

Licensed Mississippi Agent

(SEAL)

______________________________________________

(Type or Print Name of Agent)

______________________________________________

(Telephone Number)

Form 72-442-05-1-1-000 - Contractor'S Blanket Sales, Use, Income, Franchise, Withholding, And Special Fuel (Diesel Fuel) Tax Bond

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