Form 70xn - Nebraska Motor Fuels Tax Bond Rider
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Nebraska Motor Fuels Tax Bond Rider
FORM
70XN
If combined bond, complete schedule on page 2.
1 Nebraska ID Number
2 Federal Employer ID or Social Security
3 Surety Bond Number
4 Was a combined bond issued?
Number
YES
NO
If Yes, complete schedule on page 2.
NAME AND LEGAL ADDRESS SHOWN ON LICENSE OR PERMIT
PRINCIPAL’S NAME AND MAILING ADDRESS
Name
Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
5 Fuel Tax Program(s) Covered by Bond Prior to Amendment
Motor Fuels Tax
Producer
Aircraft Fuels Tax
Compressed Fuel Tax
6 Type of Change Requested (see instructions)
7 Amount of Bond After Amendment
Change in Amount of Bond
Change in Name
8
Effective Date of Change
Change Bond Effective Date __________________________
Change in Ownership
Month
Day
Year
Change in Form of Ownership
9 Explanation of Changes
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
All provisions and conditions of the bond to which this rider is attached remain unchanged
except for the specific changes made by this rider.
The liability of the surety under the bond and under this rider shall not be cumulative.
sign
here
Original Signature of Principal
Date
Original Signature of Attorney-in-Fact or Authorized Surety Company Officer
Date
Original Signature of Agent
Date
Mail this rider to: Motor Fuels Division, PO Box 98904, Lincoln, NE 68509-8904.
9-2013
3-209-1977 Rev.
Page 1
Supersedes 3-209-1977 Rev. 11-2010
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