Fillable Form M-219 - Permit Fee Bond printable pdf download

Indiana Department of Revenue

Form M-219

State Form 41528

Permit Fee Bond

(R2 / 7-11)

Surety bond given by: ______________________________________________

of ___________________________________

Name of Principal

Street Address

City/Town of _________________________ County of __________________ and State of ______________ as principal, and

Name of City or Town

Name of County

Name of State

___________________________________________

of ________________________________________________________ ,

Name of Surety

Street Address

City

State

Zip Code

as surety, to the State of Indiana in the sum of ___________________ dollars, for the payment of which we bind ourselves, our heirs,

executors, administrators and assigns. The above principal has applied for, and, subject to the execution of a bond as provided by

law, has obtained Quarterly Billing Authorization to move oversize loads over State and Federal Highways, as granted by the Indiana

Department of Revenue in accordance with Title 9 of the Indiana Code.

If the above principal, _______________________________________ , shall do and perform the things agreed by the principal in

the permit and the Transporting Agreement and shall pay all permit fees, within 20 days after the end of each calendar quarter, for the

movement of each oversize load moved over State and Federal Highways then this obligation shall be void, otherwise it remains in

full force and effect.

It is expressly understood and agreed that the liability of the Surety for any and all claims hereunder shall in no event exceed the penal

sum of this obligation as herein stated. If the surety shall so elect, this bond may be canceled by giving 60 days’ written notice of such

cancellation to the principal and a like 60 days’ written notice to the Indiana Department of Revenue, Motor Carrier Services Division,

hereinafter referred to as the Division. Cancellation shall become effective at the expiration of 60 days from the Division’s receipt

of written notice, unless a new bond is ﬁ led by such principal and approved by the Division prior to such times, in which event such

cancellation shall be effective from the date of the approval of such new bond. Notice of the cancellation shall not affect the liability

of the surety for any acts or omission of the principal occurring prior to the date when the cancellation shall become effective, but the

surety shall continue to be liable under all of the provisions of this bond for all acts and omissions of such principal occurring prior to

the cancellation to the same extent as if such notice of cancellation had not been given. The principal binds himself, his successors

and assigns, upon receipt of such notice and within said period of 60 days, to prepare and ﬁ le with the Division a new bond to the

satisfaction and approval of said Division, in the sum required by the Division with surety to be approved by said Division.

This bond is a continuing bond and shall continue in full force and effect from its effective date of ___________________________

20________ , until cancelled in the manner set herein, or the ﬁ ling of a new bond as required by the Division.

IN WITNESS WHEREOF, we hereunto set our hand and seal this _______________ day of ________________, 20_____________

________________________________________________

Principal

Attest:

By ______________________________________________

Owner or President

__________________________________________________

________________________________________________

Secretary of Corporation

Surety

By ______________________________________________

President

STATE OF: ________________________________________

________________________________________________

}

Resident Agent

___________________________________________ COUNTY

SS:

Before me, the undersigned, a Notary Public within and for the County and State aforesaid, this _________ day of ______________

20_____, personally appeared _________________________________________________________________and acknowledged

the execution of the foregoing bond.

Witness my hand and seal this date _____________________________________________________________________________

Notary Public

My commission expires: _______________________

Form M-219 - Permit Fee Bond

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