WV/CEM-B
Org. 03/2023                 WEST VIRGINIA TAX DIVISION
                                   TAX ACCOUNT ADMINISTRATION
                             PRENEED CEMETERY COMPANY BOND

                                                 BOND NUMBER:
                                          (See Instructions On Reverse Side)

     KNOW ALL MEN BY THESE PRESENTS:

(1) That we,
(2) Address
(3) as Principal, and
(4) Address
    a corporation authorized to do business in the State of West Virginia, as surety, are held and
(5) firmly bound, effective the           day of                  , 20                , unto the State of West Virginia in the sum
    of_________ thousand dollars, lawful money of the United States of America, to be paid to the State of West Virginia, to which
    payment well and truly to be made we do hereby and ourselves, jointly and severally, our successors and assigns firmly by these
    presents.
    WHEREAS, the above bound Principal is a cemetery company within the meaning of Chapter 35, Article 5B of the Official Code
    of West Virginia of 1931, as amended, and whereas the Tax Commissioner of the State of West Virginia has required the said
    Principal to deposit a Bond, in accordance with the provisions of Chapter 35, Article 5B, Section 4 of the said Code of West
    Virginia.
    The continuing nature of this Bond is that it is required to be renewed every year on its anniversary date which will run
    concurrently with the registration period unless any of the signatories hereto notifies the West Virginia Tax Commissioner by
    Certified Mail that the signatory desiring the cancellation intends to cancel this Bond sixty days after the postmarked date of the
    written notice.
    NOW THEREFORE, if the said Principal shall in all respects fully comply with the provisions of Chapter 35, Article 5B of the said
    Code of West Virginia and the rules and regulations adopted and promulgated thereunder, and shall account for and pay all
    damages for which the said Principal shall be liable, and shall protect and save harmless the State of West Virginia or a private
    person from any loss arising from the failure of the Principal to pay such damages, for any cause whatsoever,
    then this obligation shall be void; otherwise to remain in full force and effect.
    The Principal hereby waives the secrecy provisions of West Virginia Code § 11-10-5(d) and authorizes the    WEST VIRGINIA
    TAX DIVISION to release to the Surety Company all information necessary to file a proof of claim concerning any liability 
    covered by this Bond and accruing during the effective dates of this Bond.
    IN WITNESS WHEREOF, the said Principal has hereunder set his or its hand and affixed his or its seal, and the said surety has
    caused its corporate name to be signed hereto and its corporate seal to be hereunto affixed by its duly authorized official or agent
    and executed.
(6) this instrument this the                     day of                                        , 20                           .

                                                          (7)                                                                 (Seal)
                                                                                      Principal
    Principal                                           (8)       By:                                                         (Seal)
(9) Corporate Seal                                                                    Title
                                                                  (Must be President or Vice President)
                                                        (10)
                                                                                      Surety
    Surety                                              (11)      By:                                                         (Seal)
(12) Corporate Seal

(13) Countersigned:
                     Resident West Virginia Agent

                                     (See Bond Form, Other Side)

IF THE PRINCIPAL IS INDIVIDUAL, COMPLETE PAGE 1, LINES 1-9;  HAVE NOTARY COMPLETE PAGE 2, LINES 14-22; AND SURETY
COMPLETE PAGE 1, LINES 10-13 AND PAGE 2, LINES 34-44.
IF PRINCIPAL IS COMPANY OR CORPORATION, COMPLETE PAGE 1, LINES 1-9; HAVE NOTARY COMPLETE PAGE 2, LINES 23-33
AND SURETY COMPLETE PAGE 1, LINES 10-13 AND PAGE 2, LINES 34-44.

(1-2)   Enter name and address of Principal (individual, company or corporation to be covered by Bond).
(3-4)   Enter name and address of Surety Company issuing Bond.
(5)     This Bond shall remain in full force and effect so long as a renewal certificate is furnished on or before the anniversary
        date of the effective date of the Bond.
(6)     Enter bearing date of Bond (also known as the execution date of Bond).
(7)     Enter the name of Principal (the individual, company or corporation covered by the Bond).
(8)     If the Principal is an individual, affix your signature here.  If signing for a company or corporation, president or vice-
        president should sign.  (If signed by other than president or vice-president, a copy of resolutions must be attached
        showing authorization of individual to bind corporation.)
(9)     If Principal is company or corporation, affix corporate seal.
(10)    Enter name of Surety Company.
(11-13) Affix signature of person having Power of Attorney to bind Surety Company.  If Surety’s agent is non-resident, a resident
        agent licensed to this State must countersign the Bond.  Counter Signature should be entered in lower left hand portion
        of Page 1 of Bond.
(12)    Affix corporate seal of Surety Company.

IF THE TRUSTEE IS OTHER THAN A BANK, SAVINGS AND LOAN OR OTHER FEDERALLY INSURED INVESTMENT BANKING
INSTITUTION, THE TRUSTEE SHALL FURNISH A FIDELITY BOND WITH CORPORATE SURETY THEREON, PAYABLE TO THE
TRUST ESTABLISHED, IN A SUM EQUAL TO BUT NOT LESS THAN ONE HUNDRED PERCENT OF THE VALUE OF THE PRINCIPAL
OF  THE TRUST ESTATE AT THE BEGINNING OF EACH CALENDAR YEAR, WHICH BOND SHALL BE DEPOSITED WITH THE TAX
COMMISSIONER.

                                  (See Instructions On Reverse Side)
                                  (Acknowledgment if Principal is Individual)
(14) STATE OF
(15) County of                                       , to-wit:
(16) I,                                                       a Notary Public in and for the county  and state aforesaid, do
(17) hereby certify that                                                                                            ,
(18) whose name is signed to the foregoing writing, bearing the date the      day of                    , 20         ,
     has this day acknowledged the same before me in my said county.
(19) Given under my hand this the    day of                                   , 20            .

(20) Notary Seal                     (21)                                                           Notary Public
(22) My commission expires on the    day of                                   , 20            .
                              (Acknowledgment by Principal if Corporation)
(23) STATE OF
(24) County of                                       , to-wit:
(25) I,                                                       a Notary Public in and for the county  and state aforesaid, do
(26) hereby certify that                                                                                            ,
(27) who, as                         signed to the foregoing writing for
(28)                                 , a corporation, bearing the date the                                  day of
(29)                          , 20         , has this day, in my said county, before me, acknowledged said writing to be the act and
     deed of said corporation.
(30) Given under my hand this the    day of                                   , 20            .

(31) Notary Seal                     (32)                                                           Notary Public
(33) My commission expires on the    day of                                   , 20            .
                                     (Acknowledgment for Surety)
(34) STATE OF
(35) County of                                       , to-wit:
(36) I,                                                       a Notary Public in and for the county  and state aforesaid, do
(37) hereby certify that                                                                                            ,
(38) who, as                         signed to the foregoing writing for
(39)                                 , a corporation, bearing the date the                                  day of
(40)                          , 20         , has this day, in my said county, before me, acknowledged said writing to be the act and
     deed of said corporation.
(41) Given under my hand this the    day of                                   , 20            .

(42) Notary Seal                     (43)                                                           Notary Public
(44) My commission expires on the    day of                                   , 20            .

Sufficiency in Form and Manner of Execution Approved                          Attorney General
Dated this                    day of                 , 20                .  By
                                                                              Assistant Attorney General

                                          (See Bond Form, Other Side)

IF PRINCIPAL IS AN INDIVIDUAL, HAVE NOTARY COMPLETE LINES 14-22 AND SURETY COMPLETE LINES 34-44.
(14) Enter name of State.
(15) Enter name of County.
(16) Enter name of Notary Public witnessing transaction.
(17) Enter name of individual (Principal) covered by Bond.
(18) Enter bearing date of Bond (also known as execution date).  Must be same as date entered on Page 1, Line 6 of the Bond.
(19) Notary enters date Bond was witnessed.  May be same as bearing date or any day thereafter.
(20) Affix Notary Seal.  If Notary is located outside of West Virginia, seal must be affixed.
(21) Notary affixes his signature here.
(22) Notary enters commission date.
IF PRINCIPAL IS COMPANY OR CORPORATION, HAVE NOTARY COMPLETE LINES 23-33 AND SURETY COMPLETE LINES 34-44.
(23) Enter name of State.
(24) Enter name of County.
(25) Enter name of Notary Public witnessing transaction.
(26) Enter name of Corporate office signing Bond (should be president or vice-president).  See additional instructions on Page 1,
     Line 8 or 9.
(27) Designate title of Corporate Officer signing Bond.
(28) Enter name of Corporation or Company.
(29) Enter bearing date of Bond (also known as execution date).  Must be same as date entered on Page 1, Line 6 of the Bond.
(30) Notary enters date Bond was witnessed.  May be same as bearing date or any day thereafter.
(31) Affix Notary Seal.  If notary is located outside of West Virginia, seal must be affixed.
(32) Notary affixes his signature here.
(33) Notary enters commission date.
ACKNOWLEDGMENT FOR SURETY.  INDIVIDUAL, COMPANY OR CORPORATION MUST HAVE THIS PORTION COMPLETED.
(34) Enter name of State.
(35) Enter name of County.
(36) Enter name of Notary Public witnessing transaction.
(37) Enter name of person having power of attorney to bind Surety Company.
(38) Designate title of person binding Surety Company.
(39) Enter name of insurance company (Surety).
(40) Enter bearing date of Bond (also known as execution date).  Must be same as date entered on Page 1, Line 6 and Page 2,
     Line 18 or 28.
(41) Notary enters date Bond was witnessed.  May be same as bearing date or any day thereafter.
(42) Affix Notary Seal.  If notary is located outside of West Virginia, seal must be affixed.
(43) Notary affixes his signature here.
(44) Notary enters commission date.
Power of Attorney for Surety must be attached and it must show that it was in full force and effect on bearing date (execution
date) indicated on Page 1; also, corporate seal must be affixed to Power of Attorney.