Form GEN-BR "Surety Bond Rider - Tax Liability Rider or Name Change Rider" - North Carolina

What Is Form GEN-BR?

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 July 1, 2021;
  • 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 GEN-BR 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 GEN-BR "Surety Bond Rider - Tax Liability Rider or Name Change Rider" - North Carolina

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GEN-BR
4
Surety Bond Rider - Tax Liability
Web-Fill
Rider or Name Change Rider
7-21
PRINT
CLEAR
AMENDING BOND NO.
______________________________________________________________________________________________, (“Principal”) and
___________________________________________________________________________________________________, (“Surety”),
previously executed a surety bond effective _____________________________________________________ in favor of North Carolina,
as obligee. The surety bond was issued under the bond number identified above, remains in effect, and is applicable to tax liability for:
Alcoholic Beverages
Tobacco Products Cigarettes
Tobacco Products Other Than Cigarettes
Motor Fuel/Alternative Fuel.
The bond identified above is amended as follows:
Change Tax Liability (Bond) Amount
The previously issued bond is hereby amending by increasing or decreasing the bond amount from the sum of USD
______________________________________________________ (US$______________________________) to the sum of USD
______________________________________________________ (US$______________________________).
The amended bond amount is applicable to acts or omissions on or after the _______ day of _____________, 20______.
Change Name of Principal
The previously issued bond is hereby amended by changing the name of the Principal from:
___________________________________________________ to _________________________________________________.
(Previous Name)
(New Name)
The amended Principal’s name is effective the _______ day of _____________, 20______.
This rider will become a part of the bond and does not waive, alter, modify, or terminate any other terms of the bond. Principal or Surety
shall send this rider to the North Carolina Department of Revenue for approval after it has been executed.
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
GEN-BR
4
Surety Bond Rider - Tax Liability
Web-Fill
Rider or Name Change Rider
7-21
PRINT
CLEAR
AMENDING BOND NO.
______________________________________________________________________________________________, (“Principal”) and
___________________________________________________________________________________________________, (“Surety”),
previously executed a surety bond effective _____________________________________________________ in favor of North Carolina,
as obligee. The surety bond was issued under the bond number identified above, remains in effect, and is applicable to tax liability for:
Alcoholic Beverages
Tobacco Products Cigarettes
Tobacco Products Other Than Cigarettes
Motor Fuel/Alternative Fuel.
The bond identified above is amended as follows:
Change Tax Liability (Bond) Amount
The previously issued bond is hereby amending by increasing or decreasing the bond amount from the sum of USD
______________________________________________________ (US$______________________________) to the sum of USD
______________________________________________________ (US$______________________________).
The amended bond amount is applicable to acts or omissions on or after the _______ day of _____________, 20______.
Change Name of Principal
The previously issued bond is hereby amended by changing the name of the Principal from:
___________________________________________________ to _________________________________________________.
(Previous Name)
(New Name)
The amended Principal’s name is effective the _______ day of _____________, 20______.
This rider will become a part of the bond and does not waive, alter, modify, or terminate any other terms of the bond. Principal or Surety
shall send this rider to the North Carolina Department of Revenue for approval after it has been executed.
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