Form Mf-134 - Cash Bond Form
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3INDIANA DEPARTMENT OF REVENUE
MF-134
State Form 46843
(R3 / 12-08)
Cash Bond Form
Gasoline
$
Applicant's Money Held in Escrow
Cash Bond Number
Special Fuel
$
Applicant's Money Held in Escrow
Prepaid
$
Applicant's Money Held in Escrow
License Number
PREPAID / GASOLINE / SPECIAL FUEL CASH BOND
KNOW ALL MEN BY THESE PRESENTS:
Cash bond given by
of
(Name of Principal - Surety)
to the State of
(Street Address, City, County, State, Zip Code)
Indiana in the sum of
Dollars, for the payment of
which we bind ourselves, our heirs, executors, administrators and assigns.
The above Principal-Surety,
,
(Name of Principal - Surety)
has applied for, and, subject to the approval of this cash bond as provided by law, has obtained a prepaid
gasoline and/or special fuel license(s) to engage in business as defi ned by both Indiana Code 6-6-1.1 et. seq.
and Indiana Code 6-6-2.5 et. seq. all related acts and regulations. Thus, if the Principal - Surety becomes
duly licensed and does comply with all provisions of Indiana Code 6-6-1.1 et. seq. and Indiana Code 6-6-2.5
et. seq and all related acts and regulations and does satisfy all taxes, penalties, and forfeitures prescribed
pursuant to Indiana Code 6-6-1.1 and Indiana Code 6-6-2.5 et. seq. , and all related acts and regulations,
then this obligation shall be null and void; otherwise, it shall be and remain in full force and effect.
This instrument is in full force and effect from its effective date,
,
20
, and shall not expire until cancelled as provided by this instrument. Cancellation may be effected
by any party to this instrument by giving the other parties sixty (60) days written notice, as provided by law.
Notice of cancellation shall not affect liabilities of the Principal - Surety for its own acts or omissions prior
to the effective date of the cancellation. This bond shall remain in full force and effect for all liabilities
which occurred before and including the effective date of the cancellation and for a period of three (3)
years and one (1) day after the expiration of the bond as provided by this instrument, unless written notice
is issued by the Administrator to the effect that all obligations due the State of Indiana have been paid.
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