Form Modes-4252 - Surety Bond (Financial Guarantee For Payment Of Contributions) printable pdf download

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS

DIVISION OF EMPLOYMENT SECURITY

REQUIREMENTS FOR COMPLETING FORM

421 East Dunklin Street, Post Office Box 59

1. Issued by licensed insurance company

Jefferson City, MO 65104-0059

2. Signed by Attorney-In-Fact

SURETY BOND

3. Signed by applicant

(Financial Guarantee for Payment of Contributions)

4. Must bear insurance company seal

5. Must have effective date

Bond Number

6. Must be accompanied by a valid Power of

Attorney letter

That I/We _________________________________________________________________________________________________

(Owner’s Name)

(Business Name)

of _____________________________________________________County, State of ____________________________________

as principal, and____________________________________________________________________________________________

(Name of Surety Company)

a corporation duly licensed for the purpose of making, guaranteeing, or becoming sole surety upon bonds required or authorized by

the laws of the State of Missouri, as surety, are held and firmly bound to the Missouri Department of Labor and Industrial Relations,

Division of Employment Security, in the penalty sum of ____________________________________________________________

____________________________________ DOLLARS ($____________._____), lawful money of the United States, to be paid to

the Missouri Division of Employment Security, for which sums of money, well and truly to be paid, we bind ourselves, our heirs,

successors, assigns, executors, and administrators, jointly and severally, firmly by these presents.

THE CONDITION OF THE FOREGOING OBLIGATION IS SUCH THAT,

Whereas, under Section 288.032.2 of the Missouri Employment Security Law, Chapter 288 RSMo, a lessor employing unit

may post a bond of an amount as specified therein to insure timely payment of contributions, payments in lieu of contributions,

interest, penalties, and surcharges for which the lessor employing unit may be, or become, liable under the Employment Security

Law; and,

Whereas, not later than the end of February of each calendar year hereafter, the specified amount of the bond will be adjusted

if necessary; and,

Whereas, said bond shall be deposited with the Director of the Missouri Division of Employment Security and maintained for

safekeeping by said Director; and,

Whereas, the following lessor employing unit wishes to post with the Director of the Missouri Division of Employment

Security a Surety Bond:

NAME OF LESSOR EMPLOYING UNIT _________________________________________________________________

BUSINESS ADDRESS _________________________________________________________________________________

MAILING ADDRESS __________________________________________________________________________________

FEDERAL IDENTIFICATION NUMBER __________________________________________________________________

MO. DES ACCOUNT NUMBER _________________________________________________________________________

MODES-4252 (09-10) AI

Legal

Form Modes-4252 - Surety Bond (Financial Guarantee For Payment Of Contributions)

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