Form Rev-1075 - Bond Cigarette Stamping Agency

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REV-1075 AS (3-07)
Commonwealth of Pennsylvania
BOND
TO BE COMPLETED BY SURETY COMPANY
PA Department of Revenue
BUREAU OF BUSINESS TRUST FUND TAXES
CIGARETTE STAMPING AGENCY
CIGARETTE TAX UNIT
PO BOX 280909
BOND NUMBER
Harrisburg, PA 17128-0909
Please read these instructions before providing the information requested on this bond.
GENERAL INFORMATION:
Items (7) & (8) - We have set the bond amount on the basis of information received from the principal and Department records.
Item (9) - We have dated the bond as of the date it was approved as to form and manner of execution by the Department's Office of Chief Counsel.
MUST COMPLETE ITEMS 1, 2, 11, 12 AND 13:
(1) The name on the bond must be identical to the name on the agency's license. If you are doing business under a fictitious name, please
show the legal name, followed by D/B/A, followed by the fictitious name and a copy of your fictitious name filing with the PA
Department of State.
(2) Please give the full address of the principal place of business.
(11) If you represent a corporation, please show on the reverse side the corporation name as it appears on the corporate charter.
Directly below the corporate name, the corporation's president must sign the form in ink. The signature must be handwritten,
facsimilies will not be accepted. The corporation's secretary must sign to attest to the president's signature.
The Social Security Number of both the president and secretary must be entered in the space provided. The corporate seal
must be affixed where designated.
(12) If you are an individual or a member of a partnership or an association, please sign the form and enter your title and
Social Security Number in the space(s) provided. The signature must be handwritten. Facsimilies will not be accepted.
(13) Each signature must be witnessed in the area designated.
SURETY MUST COMPLETE ITEMS 3, 4, 5, 6, 10 and 14.
Show bond number in area designated at upper right-hand corner on the face of the bond.
(3) Fill in the name of the surety company.
(4) If the surety company is a corporation, the state of organization must be furnished in the space provided.
(5) & (6) Show the street, number, city and state of the office for execution of this bond.
(10) Show the date of the contract between principal and surety.
(14) The name of the surety company must be shown on the line provided.
The bond must be signed by an agent of the surety company whose authority to execute on its behalf is supported by a
current, valid Power of Attorney, a copy of which is to be attached to the bond form.
The corporate seal of the bonding company must be affixed to the bond in this area.
When the agent designated by the Power of Attorney is not a Pennsylvania resident agent, the bond must be counter-
signed by a Pennsylvania resident agent of the insurance company executing the Bond. Please type name under signature.
KNOW ALL MEN BY THESE PRESENTS, THAT
(1)
(Name of Agent)
(Legal Name-D/B/A)
OF (2)
(Post Office Box)
(Street and Number)
(City)
(County)
(State)
(ZIP Code)
as PRINCIPAL, and (3)
(Name of Surety)
organized under the laws of (4)
a corpora-
tion and duly authorized to engage in business in the Commonwealth of Pennsylvania, with its office for execution of this bond located at
(5)
in the
City of (6)
State of
as SURETY are held and firmly bound
unto the Commonwealth of Pennsylvania in the sum of (7)
dollars (8) ($
) lawful money of the United States of America, to be paid to the said
Commonwealth of Pennsylvania, to which payment well and truly to be made, we bind ourselves and each of us, our and each of our heirs, execu-
tors, administrators, successors and assigns, jointly and severally, firmly by these presents.
(9) This bond to be effective as of
A.D.
(Month)
(Day)
(Year)
WHEREAS the above bonded PRINCIPAL has been appointed by the PA Department of Revenue as an agent to affix tax stamps to ciga-
rettes in accordance with the terms and provisions of Article XII of the Tax Reform Code of 1971, as amended, Act No. 141 of December 21, 1981,
effective January 20, 1982, and, as amended, Act No. 22 of 1991, effective August 19, 1991, and
WHEREAS the said PRINCIPAL has requested the Department of Revenue of the Commonwealth of Pennsylvania to deliver cigarette tax
stamps to said PRINCIPAL upon consignment.

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