Form Rev-1075 - Bond Cigarette Stamping Agency Page 2

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Now, therefore, the condition of this obligation is such that if the above bonded PRINCIPAL shall fully, faithfully and punctually comply with the pro-
visions of Article XII of the Tax Reform Code of 1971 as amended by Act No. 141 of December 21, 1981 effective January 20, 1982 and as amended, Act
No. 22 of 1991 effective August 19, 1991 and the rules and regulations promulgated thereunder by the PA Department of Revenue, and shall well and truly
pay over to the Commonwealth of Pennsylvania, through the Department of Revenue, on or before the fifteenth day of each month, all and every sum
or sums of money that may be due and owing to the Commonwealth of Pennsylvania on account of the sale or use of cigarette tax stamps during the
next preceding month and shall file with the PA Department of Revenue on or before the tenth day of each and every month; the reports required by
the rules and regulations of the Department, then this obligation shall be null and void; otherwise it shall be and remain in full force, virtue and effect.
AND, any SURETY may cancel this bond and be relieved of further liability hereon upon giving, at least, 90 days advance written
notice of the date of cancellation by registered or certified mail. Such written notice must be sent to the PA Department of Revenue, Bureau of Business
Trust Fund Taxes, Cigarette Tax Unit, PO BOX 280909, Harrisburg, PA 17128-0909 and shall not be effective unless acknowledged by the Department
of Revenue in writing. Cancellation shall not relieve the Surety of this obligation for any liability incurred prior to the date of cancellation.
AND, in the event that the above bounden PRINCIPAL shall in any respect fail to comply with the provisions of Article XII aforesaid, or shall fail
well and truly to pay over to the Commonwealth of Pennsylvania any sum or sums of money due as aforesaid, or shall fail to file with the PA
Department of Revenue the reports, required as aforesaid, we do hereby empower the Attorney General of the Commonwealth of Pennsylvania or
any attorney of any Court of record within the Commonwealth of Pennsylvania or elsewhere, to appear for and enter judgment against us or either of
us, with or without default, for all unpaid tax, interest, penalty, fines and costs of collection up to the above sum, release of all errors and without stay of
execution. And we waive the right of inquisition on any real estate which may be levied upon to collect the above sum, and we do hereby voluntarily con-
demn the same and authorize the prothonotary to enter upon the fieri facias our said voluntary condemnation. And we further agree that said real
estate may be sold on a fieri facias, and hereby waive and release all relief from any and all appraisement, stay or exemption laws of any state now
in force or hereafter to be enacted. And for the entering of such judgment and so doing this shall be the sufficient warrant, and a copy of this Bond
and Warrant being filed in such action, it shall not be necessary to file the original as a warrant of attorney, any law or rule of the court to the contrary
notwithstanding.
(10) Signed, sealed, and delivered this
day of
A.D. 20
In witness whereof this instrument has been duly executed by the above-named PRINCIPAL and SURETY the day and year above written.
(11) INCORPORATED CIGARETTE STAMPING AGENT: SIGN BELOW
(Corporate Seal)
ATTEST
Corporate Name
By
President
Social Security Number
Secretary
Social Security Number
Print Name
Print Name
(12) INDIVIDUAL, PARTNERSHIP, AND ASSOCIATION CIGARETTE STAMPING AGENT: SIGN BELOW
Signature
Print Name
Title
Social Security Number
Signature
Print Name
Title
Social Security Number
Signature
Print Name
Title
Social Security Number
(13) WITNESSES SIGN BELOW
Signature
Print Name
Signature
Print Name
(14) SURETY: COMPLETE BELOW
Name of Surety
Attorney-in-Fact
By
ATTEST
Secretary
Print Name
(Corporate Seal)
Print Name
COUNTERSIGNATURE OF RESIDENT PENNSYLVANIA AGENT
Signature
Print Name
DO NOT WRITE IN THIS SPACE
PA DEPARTMENT OF REVENUE
Accepted this
day of
A.D. 20
By
Authorized Signature
Approved as to form and manner of execution
Assistant Counsel
Date
I hereby certify on this date
that the company acting as surety on the within bond is licensed to do a
surety business in Pennsylvania and that the agent whose name appears hereon is a licensed resident agent approved by the Insurance Department
of the Commonwealth of Pennsylvania.
For Insurance Commissioner

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