Bond Of Motor Vehicle Dealer, Special Equipment Dealer, Crusher Or Body Shop Page 2

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Organizational Structure

Must check one.

Individual

Government

Business

Trust

 Sole Proprietor

 Federal

 Corporation

 Trust

 State

 General Partnership

 Tribal

 Limited Partnership

 Political Subdivision

 Limited Liability Partnership

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 

 Limited Liability Company

STATE OF ________________________

COUNTY OF _______________________

On this _ __ __ day of ____________ , in the year 20___ , before me, _____________________ , a notary public,

personally appeared before me, _____________________ , proved on the basis of satisfactory evidence to be the person whose name

is subscribed to this instrument and acknowledged he executed the same.

Witness my hand and official seal.

(NOTARY SEAL)

Notary signature: ________________________

AFFIDAVIT OF QUALIFICATION

STATE OF ________________________

COUNTY OF _______________________

_________________________________________________ being first duly sworn, on oath deposes and says

that he is the _______________________________ of said company, and that he is duly authorized to execute and deliver the

foregoing obligations; that said company is authorized to execute the same and has complied in all respects with the laws of Utah in reference to becoming

sole surety upon bonds, undertakings and obligations.

Subscribed and sworn to before me

this _______ day of __________ , 20 _ _ _ _ _

Notary signature: ________________________

(NOTARY SEAL)