WV/CAB-1                                                                                                                                                                         BOND NUMBER: __________________________ 
Rev. 5/11 
                                                                                                
                                                      WEST VIRGINIA STATE TAX DEPARTMENT 
                                                                              Revenue Division         
                                                                                                
                                                         COLLECTION AGENCY BOND 
                                                                                                
KNOW ALL MEN BY THESE PRESENTS: 
 
(1)                  That we, (Principal): __________________________________________________________________________________________ 
 
(2)                  Address: ___________________________________________________________________________________________________ 
 
(3)                  As Principal, and (Surety Company): _____________________________________________________________________________ 
 
(4)                  Address: ___________________________________________________________________________________________________ 
                     a firm and/or a corporation authorized to do business in the State of West Virginia, as Surety, are held and firmly bound unto the State 
(5)                  of West Virginia in the just and full sum of five thousand dollars ($5,000.00) to the payment whereof well and truly to make, we bind 
                     ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally, firmly by these presents. 
 
                             WHEREAS, the above bound Principal is a collection agency within the meaning of Chapter 47, Article 16, 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 47, Article 16, Section 4 of the said Code of West Virginia.; 
 
                             NOW THEREFORE, if said Principal shall in all respects fully comply with the provisions of Chapter 47, Article 16, of the 
                     Code of West Virginia, and the rules and regulations adopted and promulgated thereunder, and shall account for and pay damages for 
                     which 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 unless any of the signatories hereto give written notice by registered mail to the other signatories hereto 
                     that the signatory desiring the cancellation intends to cancel this bond sixty (60) days after the post-mark date of the written registered 
                     notice. Notices of renewal are not required. 
 
                             The Principal hereby waives the confidential provisions of West Virginia Code §11-10-5(d) and authorizes the Tax Department 
                     to release to the surety company information necessary to file proof of claim, concerning any tax liability covered by this bond and 
                     accruing during the effective dates of this bond. 
 
(6)                          This bond shall be effective from the __________ day of _______________, 20__________. 
 
                             IN WITNESS WHEREOF           the said principal has hereunder set his/her or its hand and affixed his/her 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 officer or 
                     agent and 
 
(7)                  executed this instrument this __________ day of _______________, 20 _________. 
 
                                                                                (8) ___________________________________________________________ 
                                                                                                                                                                            (Principal) 
 
                                                                               (9) By: _______________________________________________________  
  (10)             Affix   : Principal   Corporate       Seal                                  Title: Must be President or Vice-President or authorized individual 
                  (A drawn facsimile is acceptable if no corporate seal)      
                                                                                                                             ________________________________________________________          (LLCs are not required to provide a seal) 
                                                                                                               (11)     (Print Name of Person Signing) 
                                                                                               
                                                                               (12) ___________________________________________________________ 
                                                                                                                                    (Surety Company) 
 
                                                                               (13) By: _______________________________________________________ 
                                                                                                                                         (Title)  
  (14)               Affix:  Surety Corporate Seal 
 

        ACKNOWLEDGEMENT BY PRINCIPAL IF INDIVIDUAL OR PARTNERSHIP  
 
(15) State or Commonwealth of _________________________ 
 
(16) County of _________________________, to-wit: 
 
(17)  I, ___________________________________ a Notary Public in and for the county and state aforesaid, do hereby certify that 
 
(18) _________________________________________ , whose name is signed to the foregoing writing, 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 __________. 
 
     ACKNOWLEDGEMENT BY PRINCIPAL IF CORPORATION or LIMITED LIABILITY COMPANY 
 
(23) State or Commonwealth of _________________________ 
 
(24) County of _________________________, to-wit: 
 
(25)  I, ___________________________________ a Notary Public in and for the county and state aforesaid, do hereby certify that 
 
(26) ________________________________________, who as 
 
(27) ________________________________________, signed the foregoing writing for 
 
(28) ________________________________________, a corporation/LLC, 
 
(29) has this day, in my said county, before me, acknowledged the said writing to be the act and deed of the said corporation/LLC. 
 
(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 __________. 
 
       ACKNOWLEDGEMENT BY SURETY (Must be completed by the Surety Company) 
(34) State or Commonwealth of _________________________ 
 
(35) County of _________________________, to-wit: 
 
(36)  I, ___________________________________ a Notary Public in and for the county and state aforesaid, do hereby certify that 
 
(37) ________________________________________, who as 
 
(38) ________________________________________, signed the foregoing writing for 
 
(39) ________________________________________, a surety company, 
 
(40) has this day, in my said county, before me, acknowledged the said writing to be the act and deed of the 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 ________.      ____________________________________________ 
                                                                                          Assistant Attorney General 

                                                COLLECTION AGENCY BOND 
 
Should you require any assistance, please contact the West Virginia State Tax Department at (304) 558-8683. 
                                                                       
                                                PREPARATION INSTRUCTIONS 
       
      IF PRINCIPAL IS AN INDIVIDUAL OR PARTNERSHIP:  
 
        Complete the Collection Agency Bond, lines (1) through (10); 
        Have a Notary Public complete the applicable section of acknowledgement titled, Acknowledgement by Principal if 
        Individual or Partnership, on the back of bond. 
 
      IF PRINCIPAL IS A CORPORATION OR LIMITED LIABILITY COMPANY:  
 
        Complete the bond, lines (1) through (10);  
        Have a Notary Public complete the applicable section of acknowledgement titled, Acknowledgement by Principal if 
        Corporation or Limited Liability Company, on the back of bond. 
        Affix corporate seal on face of bond; Note: (Line 10) a drawn facsimile is acceptable, if no corporate seal. 
 
      SURETY 
 
        Complete the applicable portion of bond; 
        Notary Public must complete section of acknowledgement titled, Acknowledgement by Surety (back of bond); 
        Attach Power of Attorney to bond if surety signatory is an Attorney In Fact; 
        Affix raised Surety Seal to bond and to Power of Attorney. 
 
                                                LINE NUMBER INSTRUCTIONS: 
 
      FACE OF BOND CANNOT CONTAIN WHITE-OUTS OR ALTERATIONS.  REVERSE OF BOND MAY 
      CONTAIN WHITE-OUTS OR ALTERATIONS PROVIDING CHANGES ARE INITIALED BY NOTARY. 
 
(1-2)   Enter name and address of Principal (Specify individual, partnership, corporation or LLC) to be covered by bond. 
(3-4)   Enter name and address of Surety Company issuing bond. 
(5)     Enter amount of bond. 
(6)     Enter effective date of bond. 
(7)     Enter execution date of bond. 
(8)     Enter name of the Principal (individual, partnership, corporation or LLC) covered by bond. 
(9)     If principal is an individual, affix signature.  If principal is a corporation, President or Vice-President must sign and 
        print name on bond and underline the appropriate title.  If bond is to be signed by one other than the President or 
        Vice-President, affix a copy of corporate resolutions showing authorization of individual to bind corporation. 
        If Principal is an LLC, Manager or Managing Member must sign and print name and title on bond.  
(10)    If Principal is a corporation, be sure to affix raised corporate seal; if not available, draw facsimile.  
                             Note: LLCs are not required to provide a corporate seal. 
(11)                      Enter Name of person signing 
(12)    Enter name of Surety. 
(13)    Affix signature and title of person having Power of Attorney to bind Surety. 
(14)    Affix corporate seal of Surety. 
 

                        ACKNOWLEDGEMENT PREPARATION INSTRUCTIONS: 
                        (Acknowledgements must be completed where applicable) 
 
         If Principal is an Individual or Partnership:  A Notary Public must complete lines (15) through (22). 
         If Principal is a Corporation or Limited Liability Company:  A Notary Public must complete lines (23) through (33). 
         Surety Company: A Notary Public must complete lines (34) through (44). 
 
    ACKNOWLEDGEMENT BY PRINCIPAL IF INDIVIDUAL OR PARTNERSHIP (Must be completed if you qualify) 
 
(15)     Enter name of State or Commonwealth. 
(16)     Enter name of County. 
(17)     Enter name of Notary Public witnessing transactions. 
(18)     Enter name of Principal covered by bond if Individual or Partnership.  (Must be owner of Sole Proprietorship or 
         General Partner of Partnership) 
(19)     Notary Public enters date bond was witnessed.  Must be the same as or later than the signature date. 
(20)     Affix Notary Seal.  If Notary Public is located outside of West Virginia, seal must be affixed. 
(21)     Notary Public affix signature. 
(22)     Notary Public enters commission expiration date. 
 
ACKNOWLEDGEMENT BY PRINCIPAL IF CORPORATION or LIMITED LIABILITY COMPANY (Must be completed 
       if you qualify) 
 
(23)     Enter name of State or Commonwealth. 
(24)     Enter name of County. 
(25)     Enter name of Notary Public witnessing transactions. 
(26)     Enter name of Corporate Officer signing bond.  (Must be President or Vice-President of Corporation; Manager or 
         Managing Member of Limited Liability Company) 
(27)     Enter designated Title of Officer signing bond. 
(28)     Enter name of Company or Corporation. 
(30)     Notary Public enters date bond witnessed.  Must be the same as or later than the signature date. 
(31)     Affix Notary Seal.  If Notary Public is located outside of West Virginia, seal must be affixed. 
(32)     Notary Public affix signature. 
(33)     Notary Public enters commission expiration date. 
 
         ACKNOWLEDGEMENT BY SURETY (Must be completed by the Surety Company) 
 
(34)     Enter name of State or Commonwealth. 
(35)     Enter name of County. 
(36)     Enter name of Notary Public witnessing transactions. 
(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). 
(41)     Notary Public enters date bond witnessed.  Must be the same as or later than the signature date. 
(42)     Affix Notary Seal.  If Notary Public is located outside of West Virginia, seal must be affixed. 
(43)     Notary Public affix signature. 
(44)     Notary Public enters commission expiration date. 
 
                                    POWER OF ATTORNEY INSTRUCTIONS 
 
     Power of Attorney for Surety must be attached and must show that it was in full force and effect on the execution date 
     indicated on the face of the bond; also the raised corporate seal must be affixed to the Power of Attorney. 
 
      Name of Attorney in Fact must be listed.   
      Power of Attorney may not exceed imposed limitations. 
      Certificate date must be the same or later than the execution date entered on Line 7 of bond  .
      Signature of authorizing official must be affixed.  (Signature may be facsimile). 
      Raised seal must be affixed.