484418

KANSAS DEPARTMENT OF REVENUE TOBACCO PRODUCTS DISTRIBUTOR’S TAX BOND Bond #: (Bond will not be accepted without #)

KNOW ALL MEN BY THESE PRESENTS: THAT with main (Principal) office location at as Principal, and (Street Address, City, State, Zip) the a corporation authorized to (Surety Company Name) transact business in Kansas, as surety, are held and firmly bound unto the STATE OF KANSAS in the penalty sum of _ thousand dollars ($ ), lawful money of the United States, to the payment of which, well and truly to be made, we hereby bind ourselves, our heirs, executors, administrators, assigns and successors firmly by these presents. Whereas, the above-named principal, a LICENSED DISTRIBUTOR OF TOBACCO PRODUCTS within the provisions of K.S.A. 79- 3374, is authorized to distribute tobacco products at its licensed location at:

(Street Address, City, State, Zip) and is required by such law to comply with all the provisions of said law together with the rules and regulations pursuant thereto, as adopted by the Director of Taxation and to make such reports and furnish such information as the Director of Taxation may require, to said Director at his office in Topeka, Kansas; and to further pay all taxes due and owing the State of Kansas as provided in said Kansas Tobacco Products Law. The forfeiture of any Distributor’s Bond shall be in an amount equal to all such taxes, penalty and interest owing the State of Kansas. NOW, THEREFORE, The condition of this obligation is such that if the above-named principal shall faithfully comply with all the provisions of K.S.A. 79-3374, together with the rules and regulations promulgated by the Director of Taxation pursuant thereto, then this obligation shall be void and of no effect; otherwise it shall be and remain in full force and effect. Said 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 , (Year) Witness our hands at , Kansas, this day of , (Year)

(Principal)

By (Indicate Position: President, Vice-President, Partner, Owner)

(Surety) SEAL (Surety Address)

(Surety Company Phone Number)

By (Surety Signature)

Its (Bond shall be accompanied by power of attorney for attorney-in-fact. A Kansas licensed agent of the surety must countersign.

(Extract from K.A.R. 92-17-5) Any surety on a bond furnished by a tobacco products distributor as provided herein shall be released and discharged from any and all liability to the state accruing on such bond after the expiration of sixty days from the date upon which such surety shall have lodged with the director a written request to be released and discharged, but this provision shall not operate to relieve, release, or discharge the surety from any liability already accrued or which shall accrue before the expiration of the sixty-day period. If you need any additional copies of the form you can find them at: http://ksrevenue.org/bustaxtypescig.html or have any questions, please contact Cigarette Tobacco at 785-368-8222 or email [email protected]

TB-85 Rev. 10-18