Form Rv-F1307501 - Pledge Of Collateral To The Department Of Revenue Of The State Of Tennessee Page 2
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1
2DATE: _____________________
THE DEPARTMENT OF REVENUE OF THE STATE OF TENNESSEE
__________________
ACCOUNT NUMBER:
NASHVILLE, TENNESSEE
PLEDGE OF COLLATERAL TO THE DEPARTMENT
OF REVENUE OF THE STATE OF TENNESSEE
1.
The undersigned has executed and delivered to the Department of Revenue of the state of Tennessee a bond dated
_____________________, by which the undersigned guarantees payment of the taxes plus penalty and interest as
may accrue by the law from ________________________________(taxpayer) to the Department of Revenue of the state
of Tennessee.
2.
As collateral for such bond and in consideration therefore, the undersigned has this day pledged to the Department
of Revenue of the state of Tennessee the following Certificate of Deposit as collateral security for the performance of
said bond to-wit:
DATE OF
DATE OF
CERTIFICATE
FINANCIAL INSTITUTION
AMOUNT
ISSUANCE
MATURITY
NUMBER
____________________________________
_________
__________
__________
____________
3.
This pledge creates a security interest for all sums of money for which the undersigned may now or hereafter be
liable to the Department of Revenue of the state of Tennessee under said bond for failure to report and/or pay taxes,
penalty and interest owing, in the aforementioned Certificate of Deposit.
4.
In the event any default be made at any time of the payment of the aforementioned taxes, penalty and interest of the
undersigned on said bond, then or at any time thereafter, at the election of the Department of Revenue of the state of
Tennessee or its delegate to sell, assign, or make presentment of and deliver, all or any part of said Certificate of
Deposit, including subtractions and additions thereto, without notice to redeem, or notice of the time, place and
manner of such assignment or presentment, all of which is expressly waived by the undersigned:
(a) Notice of seizure shall be given as is notice of seizure under T.C.A. Section 67-1-1414 and such sale shall be
conducted as provide for the sale of property seized, pursuant to T.C.A. Section 67-1-1415 through 67-1-1419
provided that the county wherein such seizure is made, referred to in T.C.A. Section 67-1-1415 shall be deemed to be
Davidson County, Tennessee; and further provided that all rights of the undersigned and all those claiming through
or under the undersigned are expressly waived; and
(b) The undersigned expressly agrees that the presentment of said Certificate of Deposit by the Commissioner
of Revenue of the state of Tennessee or the Commissioner’s delegate may be presentment of all or any part of said
Certificate of Deposit at the time of default or at any time thereafter, at the election of such official, and that all rights
of the undersigned and all those claiming through or under the undersigned are expressly waived.
5.
The undersigned expressly waives and releases the right of redemption of any Certificate of Deposit presented or
sold under the authority herein given.
6.
The proceeds arising from any sale, presentment, or other collection in reference to pledged property shall be applied
as is provided for the application of proceeds under T.C.A. Section 67-1-1426. The undersigned shall receive credit
only for the amount available for payment of his obligations and shall remain liable for any amount not so paid.
7.
The Department of Revenue of the state of Tennessee shall be under no obligation or liability of any kind to any
person bound with the undersigned upon any liability secured hereby in dealing with said Certificate of Deposit, or
applying the proceeds therefore, or collection therefrom, and may at the sole election of the Department of Revenue
of the state of Tennessee deliver to the undersigned or on his order, the Certificate of Deposit pledged, either with or
without the substitution of other or additional Certificates of Deposit.
8.
The Department of Revenue of the state of Tennessee shall not be obligated to take any legal steps for collection,
protection or preservation of any Certificates of Deposit pledged herewith.
9.
The rights, duties and obligations hereunder of the Department of Revenue of the state of Tennessee and the
undersigned shall, unless otherwise required by law, be governed by the laws of the state of Tennessee, as in effect
now and henceforth.
10.
Funds have been deposited with this financial institution and are to be used as collateral for a bond to insure the
payment of Tennessee taxes. It is our understanding that the taxpayer wishes to make an assignment of his right to
the aforementioned Certificate(s) of Deposit and that the Department of Revenue is authorized by him to make
demand for such Certificate(s) of Deposit upon his failure to pay Tennessee taxes owing. This institution approves of
and recognizes the assignment of the Certificate(s) of Deposit as a valid assignment and warrants to the Department
of Revenue of the state of Tennessee that this institution shall, upon demand from the Department of Revenue
promptly pay the Certificate(s) of Deposit to the Department of Revenue.
Signature:
_______________________________________________________________________
Name:
_______________________________________________________________________
Address:
_______________________________________________________________________
City:
_______________________________________________________________________
County:
_______________________________________________________________________
State:
_______________________________________________________________________
Sworn and subscribed to before me this the _______ day of _____________________, 20 ____
__________________________________________
(Notary Public)
______________________________________________
Signature & Title of Financial Institutional Officer
Sworn and subscribed to before me this the _______ day of _____________________, 20 ____
__________________________________________
RV-F1307501
(Notary Public)
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