Form Pdo-102 - Petroleum Surety Bond

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PDO-102
Petroleum Surety Bond
This bond is required by Minnesota law to ensure state petroleum taxes and fees are paid when required.
Name of Licensed Distributor
Minnesota Tax ID Number
Bond Number
Address
Contact Person
Daytime Phone
City
State
ZIP Code
Enter all information requested.
and
(name of surety)
(name of licensed distributor)
, a corporation under the laws of
and authorized to transact business in Minnesota
(name of state)
as surety, are held and firmly bound to the Minnesota Department of Revenue on behalf of the State of Minnesota for
payment in the sum of $
, to which they bind themselves, their heirs, executors, administrators, successors
(bond or surety amount)
and assigns, jointly and severally.
The conditions of the foregoing will be that the licensed distributor will be/or was issued a license in accordance with Min-
nesota Statutes, Chapter 296A, and shall observe and obey all the provisions of the Minnesota petroleum tax laws, and shall
pay all taxes, fees, fines, penalties, damages and costs as provided in the laws which may be assessed against the licensed
distributor during the time of the continuance of the license.
This bond shall be effective for up to one year, beginning
20
and ending
20
.
Licensed distributor sign below
Authorized Signature
Title
Date
Surety company sign below
Surety Signature
Title
Date
Mail to: Minnesota Revenue, Mail Station 3333, St. Paul, MN 55146-3333
Phone: 651-296-0889
Email: petroleum.tax@state.mn.us
(Rev. 8/17)

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