Form Reg-4-A - Financial Responsibility Bond printable pdf download

Illinois Department of Revenue

REG-4-A

Financial Responsibility Bond

Part 1: Financial responsibility bond type and number

Bond type: ____________________________________________

Financial responsibility bond number: _______________________

Part 2: Taxpayer and financial institution information

We, _______________________________________________________________________________________ (as principal)

Taxpayer's name and address

and _________________________________________________________________________________________ (as surety)

Name and address of surety

are bound to the people of the State of Illinois in the penal sum of $_____________________. We hereby bind ourselves, our

heirs, executors, administrators, successors, and assigns to the payment of this amount.

The condition of this bond is that if the principal (taxpayer) identified above, who has applied for the tax responsibility (bond

type) identified above, in Part 1, pays to the Illinois Department of Revenue (IDOR) all amounts becoming due from the principal

(taxpayer) under this law, then the bond will become void; otherwise, the bond will remain in full force.

The surety identified above may conditionally cancel this bond at any time by filing a written notice with IDOR by registered or

certified mail within 90 days. However, cancellation does not discharge the surety from any liability previously accrued under this

bond or that may accrue before the 90 days expire.

Part 3: Financial responsibility bond signatures and seal requirements

We have signed and sealed this bond on __ __/__ __/__ __ __ __, to be effective __ __/__ __/__ __ __ __.

You must attach a power of attorney.

(Principal's seal)

(Surety's seal)

__________________________________________

Principal's (taxpayer) signature

Surety company attorney-in-fact's signature

__________________________________________

Second principal's signature, if applicable

Attorney-in-fact's printed name

__________________________________________

Countersigned by

President's or co-partner's signature

__________________________________________

Corporate secretary's signature

Agent for surety

__________________________________________

Number and street

__________________________________________

City

State

ZIP

For official use only

Date approved: __ __/__ __/__ __ __ __

______________________________________

Month Day Year

IDOR Director's signature

License number: _____________________

REG-4-A (R-04/13)

Form Reg-4-A - Financial Responsibility Bond

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