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Form 4752 - Distributor'S Pool Bond Agreement

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MISSOURI DEPARTMENT OF REVENUE

FORM

TAXATION DIVISION

4752

P.O. BOX 300

JEFFERSON CITY, MISSOURI 65105-0300

(REV. 12-2010)

(573) 751-2611

TDD 1-800-735-2966

DISTRIBUTOR’S POOL BOND AGREEMENT

BUSINESS NAME

BUSINESS ADDRESS

CITY, STATE, ZIP CODE

As a qualified eligible purchaser or distributor with three (3) consecutive years of satisfactory tax compliance, as deter-

mined by the director, I elect to participate in the Motor Fuel Distributors Pool Bond as provided in Section 142.896,

RSMo.

I hereby certify that my company was not required to have a bond under the predecessor act, or my company has, since January

1, 1999, completed three (3) consecutive years of satisfactory tax compliance.

I fully agree that as a participant in the Pool Bond, I will contribute monthly, either through my supplier(s) or on my distributor’s

report, at the rate of $.0024 per gallon of motor fuel or $.0013 per gallon of aviation gasoline until such fund equals one million

($1,000,000) dollars. At that time, I will not be required to make further contributions until the fund has been depleted to five

hundred thousand ($500,000) dollars.

I fully agree that if I am a new participant in the Pool Bond, I will contribute monthly for a minimum of one year regardless whether

the fund has reached its maximum or not.

I further agree that a claim filed against the Pool Bond due to a default on my account does not relieve me from liability or prevent

the director from taking other actions to collect any tax, fee, penalty and interest due.

DISTRIBUTOR POOL BOND AGREEMENT MUST BE SIGNED BY AN AUTHORIZED REPRESENTATIVE OF THE COMPANY AS

LISTED ON PAGE 2, SECTION 6 OF THE LICENSE APPLICATION.

SIGNATURE OF OWNER, PARTNER OR AUTHORIZED OFFICER

PRINT NAME OF PERSON SIGNING THE APPLICATION

DATE

__ __ / __ __ /__ __ __ __

This publication is available upon request in alternative accessible format(s).

MO 860-2831 (12-2010)

Form 4752 - Distributor'S Pool Bond Agreement

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