Form Sfn 59895 - Income Tax Withholding Surety Bond
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1"For Offi ce Use Only"
INCOME TAX WITHHOLDING SURETY BOND
OFFICE OF STATE TAX COMMISSIONER
SFN 59895 (Rev. 5-2011)
Name of Principal
Address
City
State
Zip Code
Name of Surety Company
We, the above named, are held and fi rmly bound to the State of North Dakota in the penal sum of
_______________________ dollars ($_________________) for the payment of which we jointly and severally bind
ourselves, our heirs, administrators, executors, and assigns fi rmly by this obligation.
Signed this ___________ day of _____________________, _______.
We agree that as a condition of the issuance or reinstatement of the income tax withholding account, or release
of any corporate offi cer or LLC governor/manager from personal liability for the tax, penalty, and interest that may
become due on this account of the principal, or upon demand by the Tax Commissioner, a Surety Bond must be fi led
in the Offi ce of the State Tax Commissioner by the Principal. The Bond is conditioned to secure the prompt fi ling
of true reports and the full payment of any and all income tax withholding, penalty and interest, that may hereafter
accrue and become payable under the sales and use tax laws of the State of North Dakota.
We further agree that if the Principal shall fi le all reports required by the income tax withholding laws and make
full payment of any and all income tax withholding taxes which may accrue and become payable to the State of
North Dakota under the provisions of the income tax withholding laws of the State of North Dakota, then this
obligation shall be null and void. Otherwise this obligation shall remain in full force and effect.
Principal Signature
Address of Legal Residence
City
State
Zip Code
Signature of Authorized Agent for Surety Company
Address of Legal Residence
City
State
Zip Code
The original of this document must be returned to the Offi ce of State Tax Commissioner.
State of __________________________
County Of ________________________
On this ________ day of _________________________, ______, personally appeared before me the above
named __________________________________________ known to me to be the same person named in and
who executed the above obligation as Principal and acknowledged to me that he executed this obligation.
___________________________________________
Notary Public
____________________________________ County
State of ____________________________________
My Commission Expires _______________________
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