Form Rv-F1302001 - Bond Petroleum Products And Alternative Fuels (Page 2 of 2) in pdf

Form Rv-F1302001 - Bond Petroleum Products And Alternative Fuels Page 2

day of

Witness our signature on this the

, Principal

, Surety

(If signed by Attorney in Fact, attach copy of written authority)

(If a partnership, each member of partnership should sign below):

SIGNATURE OF PRINCIPAL(S) MUST BE NOTARIZED HERE

STATE OF

COUNTY OF

, before

On this

day of

, to me known to be the Principal(s) described in and who

me personally appeared

executed the foregoing instrument, and acknowledged that (he) (she) (they) executed the same as (his) (her) (their) free act

and deed.

Notary Public

My commission expires on the

day of

SIGNATURE OF ATTORNEY IN FACT* FOR SURETY MUST BE NOTARIZED HERE

STATE OF

COUNTY OF

On this

day of

, before me a

, to me known to be

notary public, personally appeared

the person who executed the foregoing instrument on behalf of

surety, and acknowledged that (he) (she) executed the same as the free act and deed of said surety.

Notary Public

My commission expires on the

day of

APPROVED:

Commissioner of Revenue

(*If this bond is executed by an attorney in fact for any party thereto, a copy of the power of attorney designating such person

as attorney in fact with the authority to execute such instruments must be attached hereto.

Form Rv-F1302001 - Bond Petroleum Products And Alternative Fuels Page 2