Form 70 - Nebraska Motor Fuels Tax Bond
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Nebraska Motor Fuels Tax Bond
FORM
70
If combined bond, complete schedule on page 2.
1 Do you hold or have you previously held a
2 Federal Employer ID or
3 Surety Bond Number
4 Total Amount of Bond
Nebraska ID Number?
Social Security Number
YES
NO
If Yes, provide the number_________________________
NAME AND LEGAL ADDRESS SHOWN ON APPLICATION
PRINCIPAL’S NAME AND MAILING ADDRESS
Name
Name
Street or Other Mailing Address
Street Address
City
State
Zip Code
City
State
Zip Code
5
EFFECTIVE DATE OF BOND
6 Indicate fuel tax licenses covered by this bond.
Minimum $20,000 bond for each license:
Minimum $10,000 bond for:
Minimum $1,000 bond for:
Month
Day
Year
Motor Fuels Tax
Producer
Aircraft Fuels Tax
Compressed Fuel Tax
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 liable to the State of Nebraska, in the
bond amount shown above.
The principal has made application for, or holds licenses or permits as indicated in this
bond. If the principal pays all taxes, penalties, and interest due, or to become due, under
the laws of Nebraska relating to such tax programs and complies with all statutory and
regulatory provisions, then this obligation shall be void; otherwise, it shall remain in full
force and effect. The obligation of this bond shall begin on the effective date indicated
above.
The bond shall be continuous until the above-named surety company provides written
notification of cancellation to the Nebraska Department of Revenue by certified mail,
return receipt request. At least 30 days notice of cancellation must be provided. The bond
shall be deemed cancelled at the end of the last day of the calendar month following the
month in which written notice of cancellation was received. The principal and surety
shall 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
Original Signature of Principal
Phone Number
Date
(
)
Original Signature of Attorney-in-Fact or Authorized Surety Company Officer
Phone Number
Date
(
)
Original Signature of Agent
Phone Number
Date
Mail this bond to: Motor Fuels Division, PO Box 98904, Lincoln, NE 68509-8904.
9-2013
3-183-1973 Rev.
Page 1
Supersedes 3-183-1973 Rev. 11-2010
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