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Form E1780 V2 Fillable Surety Bond Form
(all forms fillable on Windows, Mac, Android tablets, and iPad using Adobe Reader XI)

(Affix Corporate Seal if available) (Affix Corporate Seal if available) Address (Affix Seal if available) (Affix Seal if available) Address a corporation duly organized and existing under the laws of the State of Address Applicant name: bonded warehouse (SDCL 35 4 45) Business Name cigarette distributor (SDCL 10 50) City State Zip County City State Zip County: contractors excise tax license (SDCL 10 46A or SDCL 10 46B) interstate fuel user (SDCL 10 47B 174) Legal name of surety company: liquor wholesaler or beer distributor (SDCL 35 5) Mailing address (Mailing address is where claims and correspondence are to be sent): Mailing address: motor fuel dealer (gasoline etc SDCL 10 47B 74) My commission expires the day of 20 My commission expires the day of 20 My commission expires the day of 20 Notary Public Notary Public Notary Public of a corporation and that of a L L C or L LP and sales tax licensee or use tax licensee (SDCL 10 45 or SDCL 10 46) special fuel bulk purchaser distributor or aviation fuel dealer (diesel etc SDCL 10 47B 74) that the seal affixed to the foregoing instrument is the corporate seal of said the day and year last above written (Attorney In Fact) (Corporate Officer) (Corporation) (Individual) (Other Entity L L C & L L P ) (Partnership) 445 E Capitol Ave | Pierre SD 57501 3185 | 1 800 TAX 9188 above ACKNOWLEDGEMENT OF PRINCIPAL ACKNOWLEDGMENT OF PRINCIPAL ACKNOWLEDGMENT OF SURETY affect its obligation on this Bond The Surety hereby does waive notice of any such change extension of time or alteration of the appeared who acknowledged himself to be the authority of its Board of Directors and further acknowledges that the said instrument and the execution Bond Citation by me duly sworn did say that he is the aforesaid officer of the of By securing this bond the Principal consents to the release of returns or return information to the Surety if it becomes necessary By Typed Name By Typed Name calendar year while the bond is in force corporation that the said instrument was signed sealed and executed in behalf of said corporation by Countersigned by Typed Name County of ) County of ) County of ) County personally appeared personally known to me who being date of notice plus the above time period due in the sum of lawful money of the United States of America payable at Pierre South Da employees of the State of South Dakota without expense to the state This bond is continuous from the date of execution and is executed the same extended from calendar year to calendar year It constitutes a new and separate obligation in the amount named above for each for the purposes therein contained by signing the name of the L L C or L L P by himself as he as such being authorized so to do executed the foregoing instrument for in the state of South Dakota are held firmly bound to the State of South Dakota to secure the performance of the duties of IN WITNESS WHEREOF I have hereunto subscribed by name and affixed by official seal at IN WITNESS WHEREOF I hereunto subscribed my name and affixed my official seal at INDIVIDUAL PARTNERSHIP OR CORPORATE SURETY INDIVIDUAL PRINCIPAL Know All Men By These Presents: Bond Number: known to me or satisfactorily proven to the person whose name is known to me to be the individual described in and who executed the foregoing instrument and acknowledged to me that he of the partnership by himself as a partner of the requirements for timely filing or payment of the taxes penalties and interest described herein shall in any manner On this day of 20 before me a Notary Public in and for said On this day of 20 before me personally On this day of 20 before me personally appeared On this day of 20 before me personally appeared or until the bond is cancelled as provided herein faithfully perform all the duties and obligations imposed by law including the OTHER ENTITIES (L L C & L L P) PRINCIPAL PARTNERSHIP OR CORPORATE PRINCIPAL Principal/Applicant Information Type or print ALL information listed prompt making or filing of all reports or returns and payment of all taxes penalty and interest as provided by law as such reports PROVIDED that the Surety for consideration received hereby stipulates and agrees that no change extension of time or alteration requirements for timely filing or payment of the taxes penalties and interest described herein returns or payments become due; and the maintenance of all records and the making of the same available to the officers and Revised 08/08 same as the act of his principal for the purpose therein contained Signed and Sealed this day of 20 South Dakota Department of Revenue South Dakota Department of Revenue Uniform Surety Bond South Dakota Resident Agent State of ) State of ) State of ) subscribed as attorney in fact for and acknowledged that he executed the such partner being authorized so to do executed the foregoing instrument for the purposes therein contained by signing the name Surety/Security Information: that he as such being authorized so to do executed the foregoing instrument The applicant as Principal and the named surety company as Surety duly authorized and qualified to do business as a surety company The bond may be cancelled by the Surety as to future liability by giving written notice by certified mail to the principal and to the Department of Revenue at Pierre South Dakota and sixty days (unless a different period is indicated in the ap The principal and the surety are bound by the statutes and rules that apply for the particular license applied for as indicated The Principal is making application for one of the following licenses or renewal of one of the following licenses (mark one): The principal shall during the period beginning on the date this instrument is executed and continuing for each successive year the Principal under the license being applied for with reference to the payment of taxes penalties and interest that may become the purposes therein contained by signing the name of the corporation by himself as the Surety remains liable for all terms and conditions of this bond for all acts or occurrences prior to the thereof to be the voluntary act and deed of said corporation Title Business Name Title Business Name to make a claim upon the bond who acknowledged himself to be one of the partners of a partnership and that he as