Form Dr-156 - Florida Fuel Or Pollutants Tax Application Page 17

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DR-157
MAIL TO:
FLORIDA DEPARTMENT OF REVENUE
Fuel or Pollutants Tax Surety Bond
R. 10/13
ACCOUNT MANAGEMENT - FUEL UNIT
TC
MS 1-5730
5050 W. TENNESSEE ST.
Rule 12B-5.150
Florida Administrative Code
TALLAHASSEE, FL 32399-0160
Effective 01/14
Please complete and submit an original bond form for each fuel product type or taxable pollutant. An applicant cannot
be issued a fuel license by the Department of Revenue until the proper security is submitted. An importer’s bond is
required in addition to a wholesaler’s bond pursuant to Rule 12B-5.030, F.A.C. If further information is needed, please
contact Account Management - Fuel Unit at 850-488-6800.
State of ______________ County of _____________________________bond number __________________________________
We, ____________________________________________, as principal, and __________________________________________ ,
(name of principal)
(name of surety)
as surety, are bound to the Florida Department of Revenue on behalf of the State of Florida, in the sum of
$ _____________________________ for the payment of which we bind ourselves, our successors and assigns, heirs, and
personal representatives, jointly and severally.
Principal acknowledges that _________________ is engaged in business which is subject to the Florida Statute
(he, she, it)
identified below: (Please check the appropriate box.)
(
) Motor fuel pursuant to Chapter 206, F.S.
(
) Pollutants tax pursuant to Chapter 206, F.S.
(
) Diesel fuel pursuant to Chapter 206, F.S.
(
) Importer’s bond pursuant to section 206.051, F.S.
(
) Aviation fuel pursuant to Chapter 206, F.S. (
) Alternative fuel pursuant to Chapter 206, F.S.
THE CONDITION OF THIS BOND is that if the principal faithfully complies with the Florida statutory tax provisions
regarding such business of the principal then this bond is void; otherwise it remains in force.
The surety agrees that if the surety wishes to cancel the bond, notification must be submitted in writing to the
Department of Revenue. Surety will mail the cancellation notice to:
FLORIDA DEPARTMENT OF REVENUE
-
ACCOUNT MANAGEMENT
FUEL UNIT MS 1-5730
5050 W. TENNESSEE ST.
TALLAHASSEE, FLORIDA 32399-0160
The bond will be cancelled sixty (60) days after the Department receives notification. The surety is liable for acts
committed by the principal and covered by the terms of the bond until it is cancelled.
This bond shall be effective as of the _________ day of _____________________________, ______
(month)
(year)
__________
____________________ , _______ .
Signed this
day of
(month)
(year)
As Principal
_____________________________________________
For DOR Use Only
By
(Principal’s name)
As Surety
_____________________________________________
By
Accepted this ______ day of ________________, ______ .
(Surety’s name)
(month)
(year)
_____________________________________________
Florida Department of Revenue
(Surety’s FEIN)
_____________________________________________
By _______________________________________________
(Surety’s address)
Name
_____________________________________________
(City, State, ZIP)
__________________________________________________
_____________________________________________
By
Title
As Attorney-In-Fact and Florida Resident Agent for Surety
(Authority of Attorney-In-Fact and Florida
Account Number: __________________________________
Resident Agent must be attached)

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