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1 1 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 52 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 51
0 0 0 4 4 4 4 0 Department Use Only
0 0 0 5 5 5 5 0 Form (MM/DD/YY)
0 0 0 6 6 6 6 0 Surety Bond
331
0 0 0 7 7 7 7 0
0 0 0 8 8 8 8 0
0 0 0 9 9 9 9 0
Missouri Tax I.D.
1 1 1 0 0 0 0 1 Number Federal Employer
1 1 1 1 1 1 1 1 (Optional) I.D. Number
1 1 1 2 2 2 2 1 Select One:
1 1 1 3 3 3 3 1 r Sales and Use Tax r Motor Fuel Tax Requirements
1 1 1 4 4 4 4 1 • Issued by licensed surety company
(If required by The Department of Revenue) Motor Fuel license type (Select One): • Signed by surety company’s authorized representative
1 1 1 5 5 5 5 1 r Cigarette Tax r Distributor • Signed by taxpayer’s authorized representative
1 1 1 6 6 6 6 1 Bondr OtherTypeTobacco Products r Supplier or Permissive Supplier • Include an effective date
1 1 1 7 7 7 7 1 r Transient Employer Withholding Tax r Terminal Operator • Include a valid Power of Attorney issued
by the surety company.
1 1 1 8 8 8 8 1 r Transporter
1 1 1 9 9 9 9 1 Amount (U.S. Currency) Bond Number Issue Date (MM/DD/YYYY)
2 2 2 0 0 0 0 2 $ ___ ___ /___ ___ /___ ___ ___ ___
2 2 2 1 1 1 1 2 At the Request of Taxpayer or Business (Owner’s Name, All Partners, Corporation, or LLC Name) County
2 2 2 2 2 2 2 2
2 2 2 3 3 3 3 2 Taxpayer or Business Owner Address City State ZIP Code
2 2 2 4 4 4 4 2
2 2 2 5 5 5 5 2
__________________________________________________________ (Issuer) hereby issues this Surety Bond (bond) in favor of the Missouri Department of Revenue,
2 2 2 6 6 6 6 2 in the aggregate sum of __________________________________________________________________________ dollars ($ _______________________ ). This bond shall
2 2 2 7 7 7 7 2 secure the payment of the above indicated tax and related fees, interest, additions to tax, and penalties due the state of Missouri or the Department on or after the date of this bond.
2 2 2 8 8 8 8 2 The funds shall be paid to the Department upon a written demand for payment on the Issuer by referencing this bond. The demand for any payment shall be sent by U.S. mail. The
2 2 2 9 9 9 9 2 Issuer shall upon receipt honor all partial or full demands for payment and make payment to the Department within thirty (30) days of receipt of the demand.
3 3 3 0 0 0 0 3 The surety may cancel the bond by delivering sixty (60) days written notice to the Department. Any election to cancel this bond shall not relieve, release, or discharge the Issuer from
3 3 3 1 1 1 1 3 any liability for the indicated taxes, related fees, interest, additions to tax, and penalties of the taxpayer or business that may accrue for all periods prior to the cancellation of the bond.
The Department shall have a period of one year after the expiration or cancellation date of the sales, use, transient employer withholding and unemployment tax bond to make a
3 3 3 2 2 2 2 3 demand for payment upon the Issuer.
3 3 3 3 3 3 3 3 The Department shall have a period of 3 years after the expiration or cancellation date of the motor fuel, cigarette and other tobacco products tax bond to make a demand for payment
3 3 3 4 4 4 4 3 upon the issuer.
3 3 3 5 5 5 5 3 This agreement and any legal action pertaining thereto shall be governed by and construed in accordance with the laws of the state of Missouri. The parties understand and agree
3 3 3 6 6 6 6 3 that the exclusive jurisdiction for any action concerning this bond shall be the state of Missouri and the only venue shall be in the Circuit Court of Cole County, Missouri. The Issuer
3 3 3 7 7 7 7 3 understands and agrees that the surety shall be liable for prejudgment interest and attorney fees if it breaches its obligations under this bond.
3 3 3 8 8 8 8 3 The person signing this bond states that he or she has the legal authority to enter into this bond and to legally bind the taxpayer or business below.
3 3 3 9 9 9 9 3 Surety Name Surety Phone Number Surety Company Certificate of Authority Number
4 4 4 0 0 0 0 4 (___ ___ ___)___ ___ ___-___ ___ ___ ___
4 4 4 1 1 1 1 4 Surety Officials Name Typed or Printed Signature of Surety Official
4 4 4 2 2 2 2 4
4 4 4 3 3 3 3 4 Surety Address City State ZIP Code
4 4 4 4 4 4 4 4
4 4 4 5 5 5 5 4
4 4 4 6 6 6 6 4 Authorization for release of confidential information has been set forth at the request of the Department and does not constitute a part of, or an exhibit to, the surety bond.
4 4 4 7 7 7 7 4 I hereby authorize release of confidential tax information to the issuing Surety Company listed above for the purpose of making demand for payment on the Surety Bond
Number listed above as long as the obligation remains in force and effect. Release of this information to the named surety company does not give the surety company
4 4 4 8 8 8 8 4 authority to request information other than information concerning the delinquent periods for which a demand for payment is being made. I also release the Director of
4 4 4 9 9 9 9 4 Revenue and Department of Revenue personnel from any and all liability pursuant to any disclosure of confidential tax information that is necessary for making demand
4 4 4 0 0 0 0 4 for or receiving such payment. By signing this Authorization, I state that I have the legal authority to bind the taxpayer or business below.
5 5 5 1 1 1 1 5 In witness whereof, this taxpayer or business duly executed the foregoing this _______ day of ________________ , 20_____.
5 5 5 2 2 2 2 5 Authorization Taxpayer or Business Owner (Proprietorship, Partnership, Corporation or LLC) Title Phone Number
5 5 5 3 3 3 3 5 (___ ___ ___) ___ ___ ___-___ ___ ___ ___
5 5 5 4 4 4 4 5 Signature of Owner, Partner, Corporate Officer, or Member Print or Type Name of Person Signing This Release E-mail address
5 5 5 5 5 5 5 5
5 5 5 6 6 6 6 5 Mail To: Sales and Use or Transient Employer Form 331 (Revised 04-2021)
5 5 5 7 7 7 7 5 Withholding Tax Motor Fuel Tax Cigarette Tax Other Tobacco Products
5 5 5 8 8 8 8 5 P.O. Box 357 P.O. Box 300 P.O. Box 811 P.O. Box 3320
5 5 5 9 9 9 9 5 Jefferson City, MO 65105-0357 Jefferson City MO 65105-0300 Jefferson City MO 65105-0811 Jefferson City, MO 65105-3320
Phone: (573) 751-5860 Phone: (573) 751-2611 Phone: (573) 751-7163 Phone: (573) 751-5772
5 5 5 0 0 0 0 5 Fax: (573) 522-1722 Fax: (573) 522-1720 Fax: (573) 522-1720 Fax: (573) 522-1720
6 6 6 1 1 1 1 6 E-mail: businesstaxregister@dor.mo.gov E-mail: excise@dor.mo.gov E-mail: excise@dor.mo.gov E-mail: excise@dor.mo.gov
6 6 6 2 2 2 2 6
*14601010001*
6 6 6 3 3 3 3 6
14601010001
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6 6 666 6 6 6
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