Form Abc-804 - Surety Bond For Liquor Licenses Issued Under The Liquor Control Act
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1Kansas Department of Revenue
Alcoholic Beverage Control Division
915 S.W. Harrison Street, Room 214
Topeka, KS 66625-3512
Phone: 785-296-7015 Fax: 866-855-5025
SURETY BOND
FOR LIQUOR LICENSES ISSUED UNDER THE LIQUOR CONTROL ACT
Pursuant to K.S.A. 41-317
KNOW ALL MEN BY THESE PRESENTS: That we _______________________________________________
(Principal)
of the City of ________________________, County of _____________________, State of _________________ as
Principal, and ____________________________________________ , a corporation organized and existing
(Surety)
under and by virtue of the laws of the State of _________________, duly licensed to do business in the State of
Kansas, as surety are held and firmly bound unto the Director of the Alcoholic Beverage Control Division for and on
behalf of the State of Kansas in the penal sum of $___________________Dollars for the payment of which each of us,
do bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally.
WHEREAS, the Principal has applied for or has been licensed by the Director of the Alcoholic Beverage Control
Division of the State of Kansas as a:
Retailer
Beer Distributor
Spirits Distributor
Wine Distributor
Farm Winery
Microbrewery
Microdistillery
Manufacturer
Non-Beverage User
Special Order Shipping
NOW, THEREFORE, if the said Principal shall faithfully comply with the provisions of the Kansas Liquor Control
Act and the rules and regulations of the Director of the Alcoholic Beverage Control in all respects, and shall
promptly pay all fees, fines and taxes which may be assessed, then this obligation shall be null and void,
otherwise to remain in full force and effect. Such principal hereby authorizes employees of the Kansas
Department of Revenue to disclose to the surety herein a statement of account relating to the tax guaranteed by this
bond.
This bond is effective on and after the __________ day of ___________________, _________, unless
(Day)
(Month)
(Year)
cancellation of such bond is approved by the Director of the Alcoholic Beverage Control Division, Department of
Revenue, after having been given thirty (30) days notice by the principal and surety.
Witness our hands at ____________________, ________, this _______ day of ________________, __________.
(Location)
(State)
(Day)
(Month)
(Year)
SURETY COMPANY
(please print)
Signature of Attorney-in-Fact* for Surety Company:
Attorney-in-Fact Name:
Attorney-in-Fact Phone Number:
Surety Company Name:
Surety Company Mailing Address:
Surety Company Phone Number:
BOND NUMBER:
PRINCIPAL
(please print)
Signature of Principal or Agent:
Title:
Name:
Mailing Address:
Phone Number:
Check Entity Type:
Individual
Corporation
Partnership
LLC
LLP
Trust
Government
Other
For ABC Office Use Only
License Number(s):
Rep’s Initials:
Bond Released
Date:
Rep’s Initials:
FEIN:
Date:
Bond Demand
Date:
Rep’s Initials:
* K.A.R. 14-17-1 Bond must be accompanied by power of attorney for Attorney-in-Fact.
Clear Form
ABC-804 (Rev. 8.1.12)
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