Form GAS-1212 "Motor Fuel and Alternative Fuel Surety Bond" - North Carolina

What Is Form GAS-1212?

This is a legal form that was released by the North Carolina Department of Revenue - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2020;
  • The latest edition provided by the North Carolina Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form GAS-1212 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Revenue.

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Download Form GAS-1212 "Motor Fuel and Alternative Fuel Surety Bond" - North Carolina

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4
GAS-1212
Motor Fuel and Alternative
PRINT
CLEAR
Web-Fill
Fuel Surety Bond
7-21
BOND NO.
______________________________________________________________________________________________, (“Principal”) and
___________________________________________________________________________________________________, (“Surety”),
authorized to engage in business as a surety in the State of North Carolina, are obligated to the State of North Carolina in the sum of USD
_______________________________________________________________ (US$_________________________). We jointly and
severally obligate heirs, executors, administrators, successors, and assigns for the payment of this amount.
Principal is engaged or intends to engage in activities where the Secretary of Revenue of the State of North Carolina is requiring a bond
in accordance with Articles 36B, 36C, or 36D of Chapter 105, or Article 3 of Chapter 119 of the North Carolina General Statutes.
The terms for this bond are as follows:
1.
Principal shall file reports, pay all taxes, and otherwise comply with all applicable laws, rules, and regulations relating to licensed
activities for the sale, use, and distribution of motor fuels and alternative fuels in the State of North Carolina. This includes but is
not limited to liability incurred under Articles 9, 36B, 36C, or 36D of Chapter 105, or Article 3 of Chapter 119 of the North Carolina
General Statutes.
2.
The bond is continuing and effective for acts or omissions occurring on or after the ______ day of _________________, 20______.
3.
Surety may be released from future liability when Principal or Surety provide at least sixty (60) days’ written notice by certified
mail to the State of North Carolina, through its agent, the Secretary of Revenue at the following address: ATTN: Excise Division,
Licensing and Bonding Unit, P.O. Box 25000, Raleigh, NC 27640. If the notice is given by an agent of Surety, the notice must be
accompanied by a power of attorney. Surety is not released from any liability which accrues before Surety is released, regardless
of when the liability is discovered. Notice, as provided for in this paragraph, is a condition precedent to the release of liability
under this bond, and any attempted cancellation inconsistent with this paragraph is void, and this bond remains in effect.
4.
If Principal or Surety fail to fulfill any term of this bond, the State of North Carolina may make a claim on the bond and pursue all
available remedies.
Signed, sealed, and delivered this ______ day of ____________________, 20______.
SURETY NAME
PRINCIPAL NAME
SURETY REPRESENTATIVE SIGNATURE (SEAL)
PRINCIPAL REPRESENTATIVE SIGNATURE (SEAL)
X
X
SURETY REPRESENTATIVE PRINTED NAME
PRINCIPAL REPRESENTATIVE PRINTED NAME
TITLE
As Attorney in Fact
SURETY
PRINCIPAL
NOTARY (IF NO SEAL FOR PRINCIPAL)
Surety declares that the
Principal declares that its seal is
Principal has not affixed seal; Principal’s signature has been notarized below.
surety’s seal is affixed to this form.
affixed to this form.
State of ________________________ County of ________________________ .
This instrument was acknowledged before me on
______________________________ (date) by
______________________________ (name of person acknowledging).
SURETY
PRINCIPAL
SEAL
SEAL
Signature of Notary Public
NOTARY
SEAL
Printed Name of Notary Public
My Commission expires
Mail to: North Carolina Department of Revenue, Attention: Licensing and Bonding Unit
3301 Terminal Drive, Suite 125, Raleigh, NC 27604
4
GAS-1212
Motor Fuel and Alternative
PRINT
CLEAR
Web-Fill
Fuel Surety Bond
7-21
BOND NO.
______________________________________________________________________________________________, (“Principal”) and
___________________________________________________________________________________________________, (“Surety”),
authorized to engage in business as a surety in the State of North Carolina, are obligated to the State of North Carolina in the sum of USD
_______________________________________________________________ (US$_________________________). We jointly and
severally obligate heirs, executors, administrators, successors, and assigns for the payment of this amount.
Principal is engaged or intends to engage in activities where the Secretary of Revenue of the State of North Carolina is requiring a bond
in accordance with Articles 36B, 36C, or 36D of Chapter 105, or Article 3 of Chapter 119 of the North Carolina General Statutes.
The terms for this bond are as follows:
1.
Principal shall file reports, pay all taxes, and otherwise comply with all applicable laws, rules, and regulations relating to licensed
activities for the sale, use, and distribution of motor fuels and alternative fuels in the State of North Carolina. This includes but is
not limited to liability incurred under Articles 9, 36B, 36C, or 36D of Chapter 105, or Article 3 of Chapter 119 of the North Carolina
General Statutes.
2.
The bond is continuing and effective for acts or omissions occurring on or after the ______ day of _________________, 20______.
3.
Surety may be released from future liability when Principal or Surety provide at least sixty (60) days’ written notice by certified
mail to the State of North Carolina, through its agent, the Secretary of Revenue at the following address: ATTN: Excise Division,
Licensing and Bonding Unit, P.O. Box 25000, Raleigh, NC 27640. If the notice is given by an agent of Surety, the notice must be
accompanied by a power of attorney. Surety is not released from any liability which accrues before Surety is released, regardless
of when the liability is discovered. Notice, as provided for in this paragraph, is a condition precedent to the release of liability
under this bond, and any attempted cancellation inconsistent with this paragraph is void, and this bond remains in effect.
4.
If Principal or Surety fail to fulfill any term of this bond, the State of North Carolina may make a claim on the bond and pursue all
available remedies.
Signed, sealed, and delivered this ______ day of ____________________, 20______.
SURETY NAME
PRINCIPAL NAME
SURETY REPRESENTATIVE SIGNATURE (SEAL)
PRINCIPAL REPRESENTATIVE SIGNATURE (SEAL)
X
X
SURETY REPRESENTATIVE PRINTED NAME
PRINCIPAL REPRESENTATIVE PRINTED NAME
TITLE
As Attorney in Fact
SURETY
PRINCIPAL
NOTARY (IF NO SEAL FOR PRINCIPAL)
Surety declares that the
Principal declares that its seal is
Principal has not affixed seal; Principal’s signature has been notarized below.
surety’s seal is affixed to this form.
affixed to this form.
State of ________________________ County of ________________________ .
This instrument was acknowledged before me on
______________________________ (date) by
______________________________ (name of person acknowledging).
SURETY
PRINCIPAL
SEAL
SEAL
Signature of Notary Public
NOTARY
SEAL
Printed Name of Notary Public
My Commission expires
Mail to: North Carolina Department of Revenue, Attention: Licensing and Bonding Unit
3301 Terminal Drive, Suite 125, Raleigh, NC 27604