Form Modes-4252 - Surety Bond (Financial Guarantee For Payment Of Contributions) Page 2

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NAME(S), ADDRESS, AND SOCIAL SECURITY NUMBER OF OWNERS,
PARTNERS, OR CORPORATE OFFICIALS:
(1)_______________________________________________________________________________________________________
(2)_______________________________________________________________________________________________________
(3)_______________________________________________________________________________________________________
(4)_______________________________________________________________________________________________________
(5)_______________________________________________________________________________________________________
NOW THEREFORE, if said principal shall well and truly comply with all the provisions of the Missouri Employment Security
Law, Chapter 288 RSMo, and any amendments thereto, and in particular pay all contributions, interest and penalties promptly when
due, then this obligation shall be null and void; otherwise, it shall remain in full force and effect.
If said principal is delinquent, the Missouri Division of Employment Security will notify said surety. Surety then has thirty
(30) days in which to make payment or contact the Missouri Division of Employment Security stating reasons payment has not been
made.
The said principal authorizes the release of the confidential tax information to said surety as long as this obligation remains in
force and effect; releasing the Director of the Missouri Division of Employment Security and Division personnel from any and all
liability pursuant to any disclosures to said surety of confidential tax information resulting from release of subject information.
This obligation shall remain in force and effective for a period of not less than five (5) years from the initial date of bonding
or until the Director of the Missouri Division of Employment Security releases said principal from the bonding requirement as set
forth by Section 288.032.2 RSMo and supplement thereto. The surety may cancel the bond and be released of further liability
hereunder by delivering sixty (60) days written notice to the principal and to the Director of the Missouri Division of Employment
Security. Such cancellation shall not affect any liability incurred or accrued hereunder prior to the termination of the sixty (60) day
period.
IN WITNESS WHEREOF, we have duly executed the foregoing obligation this ____________________________________
day of ___________________________ A.D. 20____. To be effective on the __________________________________________
day of ___________________________ A.D. 20____.
Surety Company Name
ATTEST:
(Insurance Companiy Seal)
Please Print Attorney-In-Fact
Signature of Attorney-In-Fact
Surety’s Street Address or P.O. Box
City, State, Zip Code
Signature of Owner, Partner or Corporate Officer of Business
MODES-4252-2 (09-10) AI

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