*0-0-705-099*  
                                                                                 *0-0-705-099* 

                                     STATE OF WYOMING 
                                  DEPARTMENT OF REVENUE 
  NON-RESIDENT CONTRACTOR SALES AND USE TAX BOND 
                             COVERING A SINGLE CONTRACT 
                                     BOND NO.___________ 
                                                    
 KNOW ALL MEN BY THESE PRESENTS, that we the undersigned, ______ 
_______________________________________(name and form of business 
organization of the principal), as Principal, and 
_______________________________________(name of surety), a corporation 
organized to do business in the State of Wyoming, as Surety, are held and firmly bound 
unto the State of Wyoming in the sum of ___________________ Dollars 
($___________), lawful money of the United States of America, for the payment of 
which we bind ourselves, our legal representatives, successors and assigns, jointly and 
severally, firmly by these presents. 
 
 WHEREAS, the above named Principal is a nonresident general or prime 
contractor as defined by Wyo. Stat. § 39-16-301; 
 
 WHEREAS, the above named Principal has entered into a contract with 
____________________________, dated ___________________ for 
____________________________________________, a copy of which is attached and 
                                      made a part hereto; 
  WHEREAS, pursuant to Wyo. Stat. § 39-16-306(b), the Principal has elected to 
deposit with the Department of Revenue a surety bond in the amount determined to be 
sufficient by the Department of Revenue to secure the payment by the Principal of any 
sales and use tax, penalty, and interest, which may accrue to the State of Wyoming in the 
performance of the above referenced contract. Said taxes are imposed by the Selective 
Sales Tax Act of 1937, as amended, and the Use Tax Act of 1937, as amended; and 
                                                    
  WHEREAS, by executing this instrument the Surety does hereby bind and 
obligate itself unto the State of Wyoming to secure the payment by the Principal of any 
and all sales and sales and/or use taxes, penalty, and interest, which will accrue or which 
have accrued since the commencement of operations by the Principal in the State of 
Wyoming. The liability of the surety is on all sales and/or use tax, penalty, and interest 
accrued, including taxes which predate the execution of this agreement. 
 
  NOW, THEREFORE, if the Principal timely pays to the State of Wyoming all 
sales and use taxes which become due and payable under the above referenced contract 
pursuant to the Selective Sales Tax Act of 1937, as amended, and the Use Tax Act of 
1937, as amended; 
 
  THEN, this obligation shall terminate; otherwise it shall remain in force and effect. 
                                                    
  The Surety may terminate its liability hereunder at any time by giving written 
notice to the Department of Revenue and to the Principal; but such termination shall only 
become effective thirty (30) days after the actual receipt of the written notice by the 
Department of Revenue, and shall not negate any liability incurred hereunder on or prior 
to the date of such termination. 
 
                  Any action upon this bond will be governed by Wyoming law. 
                                                    
  The State will not approve this bond if any changes or alterations have been made 
                            to the printed text or entries on any portion of this form. 
                                                    
                                  Non-Resident Contractor Sales and Use Tax Bond 
                             __________________, Principal, and _________________,Surety 
                                      Bond No.________________ 
                                                  Page 1 of 2 
 
ETS Form 124 a (Rev 5/1/19) 

                                             PRINCIPAL 
               Signed and executed this ______ day of _______________, 20___. 
                                                
By: ________________________________________ 
                            (Signature) 
Corporate Seal 
________________________________________ 
                            Printed or Typed 
TITLE:________________________________________ 
 
State of:____________________________ ) 
                                             ) SS. 
County of:__________________________ ) 
 
               There foregoing surtey bond was acknowledged before me by 
               __________________________this _____day of ______________20 ___. 
 
                                               W 
Witness my hand and official seal. 
                            ____________________________________ 
                                             Notary Public 
                                                
                            My commission expires:___________________ 
                                                
                                             SURETY 
                                                
               Signed and executed this _____ day of __________, 20____. 
                            BY: _______________________________________ 
                                                
                                             Signature 
                                                                                              Corporate Seal 
                                                
                            _______________________________________ 
                                                
                                             Printed or Typed 
TITLE:_______________________________________ 
 
State of__________________________________ ) 
                                                   ) ss. 
County of________________________________ ) 
 
 There foregoing performance and payment bond was acknowledged before me 
by____________________________ this _____ day of ____________ 20 ___. 
 
Witness my hand and official seal. ______________________________________ 
                                             Notary Public 
                                                
               My commission expires: ________________________________ 
                                                
                            Non-Resident Contractor Sales and Use Tax Bond 
                                  __________________, Principal, and _________________,Surety 
                                        Bond No.________________ 
                                             Page 2 of 2 
 
ETS Form 124 a (Rev5//1/19) 

                            INSTRUCTIONS FOR PREPARING BOND 
           
1. The bond must cover four percent (4%) of the total amount due under the contract, or 
an amount determined by the Department.        
 
2. If the principal is a corporation, the person signing on behalf of the principal must 
state his/her legal capacity and he/she should be the president of the corporation. 
There must be attached to the bond a resolution or certified evidence of authority that 
the officer has the authority to sign on behalf of the principal. This is the case even if 
the person signing is the president. Impress the corporate seal where noted. If no 
corporate seal, so state. 
 
3. If the principal is a partnership, the firm name must appear in the caption of the bond, 
e.g. John Doe and James Doe, a partnership, doing business as Hub Trucking 
Company. It must be specified that a partnership is actually involved. As lest two 
partners must sign the bond. 
 
4. If the principal is jointly owned, but not a partnership, the firm name must appear in 
the caption of the bond, John Doe and James Doe, doing business as Hum Trucking 
Company. All owners must sign the bond. 
 
5. If the principal is a sole proprietorship, the name of the owner should appear in the 
caption of the bond along with a recital thereafter of the firm name (if any), e.g. John 
Doe, doing business as Hub Trucking. If there is no firm name, the sole 
proprietorship should be shown as “John Doe”. 
 
6. The surety of the bond must be a surety company licensed to do business in 
Wyoming. 
 
7. The surety company executing the bond shall attach thereto a duly executed Power of 
Attorney (or a recently certified copy thereof) showing the authority of the person 
signing as the agent for the surety company. The Power of Attorney must have been 
executed no more than six (6) months prior to the effective date of the bond. A copy 
of the Power of Attorney may be certified by any qualified person, such as a notary 
public, but the Power of Attorney must be certified by the Secretary of the corporate 
surety. 
 
8. The surety’s corporate seal must be affixed to: 1) the bond near the surety’s execution 
and 2) the certification of the attached Power of Attorney near the surety’s execution. 
 
9. Each party should sign his/her name in the identical manner as they appear in the 
caption of the bond or on the Power of Attorney. Each party may only sign his/her 
own name. 
 
10. No changes of any type may be made to the bond form. 
 
11. A certified copy of the authority of any person signing on behalf of the principal, and 
a copy of the Power of Attorney for the Attorney-in-Fact for the Surety must be 
attached to the bond or filed with the State of Wyoming, Department of Revenue. 

                             Non –Resident Contractor Sales and Use Tax Bond 

                            ___________________Principal, and ____________________Surety 

                             Bond No________________________ 

                                        Page 1of 1 

ETS Form 124 a (Rev5//1/19)