Form 97-506-10
MISSISSIPPI DEPARTMENT OF REVENUE
GAMING ESTABLISHMENT SURETY BOND
STATE OF MISSISSIPPI
BOND NUMBER _____________________
KNOW ALL MEN BY THESE PRESENTS, THAT WE _______________________________________________________,
Of the City of ___________________________________________, County of _________________________________, State of
______________________________________ as Principal, and ____________________________________________________,
a corporation incorporated under the laws of the State of __________________________________, and duly licensed to do
business in the State of Mississippi, as Surety, are held and firmly bound unto the State of Mississippi, oblige, in the just and full
sum of _________________________Dollars ($__________), for the payment of which sum well and truly to be made and done, we
bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, by these presents, and
WHEREAS, the said Principal herein, has been licensed by the Gaming Commission to be a Gaming Establishment
Licensee under and by virtue of the provisions of the Mississippi Gaming Control Act of the State of Mississippi at _____________
_______________________________________ Street in the City of _______________________________________________
County of ______________________________________________, State of Mississippi, for a term beginning the ___________ day
of _______________________, 20_____.
NOW THEREFORE, the conditions of this obligation are such that if the Principal shall faithfully observe the provisions of
the Mississippi Gaming Control Act, Miss Code Ann §75-76-1, et. seq., all amendments thereto and Rules and Regulations issued
thereunder, and shall pay all taxes due the State of Mississippi, including but not limited to sales, income, and privilege taxes; and in
addition shall pay any and all checks returned for non-payment to the Mississippi Department of Revenue then this obligation shall
be void, otherwise to remain in full force and effect, until a release from further liabilities imposed herein is granted in writing;
PROVIDED, HOWEVER, the Surety shall so elect, this bond may be cancelled at any time by the Surety giving sixty (60) days notice
in writing addressed to and receipted therefor by the Commissioner of the Department of Revenue, and upon the giving of such
notice, this bond shall be deemed cancelled at the expiration of sixty (60) days therefrom.
Witness our hand and seal this ________ day of _______________, 20____.
PRINCIPAL: _____________________________________
By: ____________________________________________
SURETY: ______________________________________
By: ____________________________________________
(If signed by Attorney in Fact, attach copy of written authority.)
The above and foregoing bond approved this _______________day of ____________________________, 20______.
DEPARTMENT OF REVENUE
By: ____________________________________________
Applicant’s Initial: ______________________