Form 59 - Nebraska Cigarette Tax Bond
Download a blank fillable Form 59 - Nebraska Cigarette Tax Bond in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form 59 - Nebraska Cigarette Tax Bond with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2FORM
Nebraska Cigarette Tax Bond
59
1 Indicate the tax program covered by this bond by checking the appropriate box.
PLEASE DO NOT WRITE IN THIS SPACE
Cigarette Wholesale Dealer’s Stamping License
RESET FORM
Common Carrier Permit to Transport Unstamped Cigarettes
2 Do you hold, or have you previously held, a Nebraska ID Number?
YES
NO
If Yes, provide the number:
3 Federal Employer ID or
4 Surety Bond Number
5 Total Amount of Bond
6 Effective Date of Bond
Social Security Number
$10,000 for a Cigarette Wholesale Dealer’s Stamping License
Month
Day
Year
$1,000 for a Common Carrier Permit to Transport Unstamped Cigarettes
PRINCIPAL’S NAME AND LOCATION ADDRESS FROM LICENSE/PERMIT
PRINCIPAL’S NAME AND MAILING ADDRESS
Name
Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
NAME AND MAILING ADDRESS OF SURETY COMPANY
NAME AND MAILING ADDRESS OF AGENT
Name
Name
Street or Other Mailing Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
CONDITION OF BOND
For valuable consideration, we, the above-named individual or firm, as principal, and the above-named
surety company, both duly qualified and authorized to transact business in the State of Nebraska,
are jointly and severally held and firmly bound unto the State of Nebraska, Department of Revenue
(Department), in the bond sum shown above.
The principal has made application to the Department for, or holds licenses or permits as indicated in
this bond. If the principal pays all taxes, penalty, and interest due, or to become due under the laws
of Nebraska relating to this tax program, and complies with all provisions and the regulations, then
this obligation shall be void; otherwise, it remains in full force and effect. The obligation of this bond
begins on the effective date indicated above.
The bond is continuous and will be canceled at 12:01 a.m. on the first day of the calendar month
following receipt of a written notice served by the surety company upon the Department in Lincoln,
Nebraska, by certified mail, return receipt requested and not otherwise, provided that at least 30 days
notice of cancellation is received by the Department, and provided further that the principal and surety
will not be discharged from any liability already due or to become due under the laws of Nebraska
guaranteed by this bond before the date of cancellation.
sign
here
Signature of Principal
Date
Email Address of Principal
(
)
Signature of Attorney-in-Fact or Authorized Surety Company Officer
Phone Number
Date
Signature of Agent
Date
Mail this bond to: Nebraska Department of Revenue, PO Box 98903, Lincoln, NE 68509-8903.
, 800-742-7474 (NE and IA), 402-471-5729
7-2013
5-115-1977 Rev.
Supersedes 5-115-1977 Rev. 10-2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial