STATE OF GEORGIA - DEPARTMENT OF LABOR 148 Andrew Young International Blvd., N.E., Suite 850 Atlanta, Georgia 30303-1751 Phone: (404) 232-3301 EMPLOYER'S STATUTORY SURETY BOND FOR REIMBURSEMENT IN LIEU OF CONTRIBUTIONS Georgia DOL Account No. Calendar Years Surety Bond No. STATE OF GEORGIA COUNTY KNOW ALL MEN BY THESE PRESENTS, That, an employer subject to the provisions of OCGA Sections 34-8-33, 34-8-34, 34-8-158, 34-8-159 and 34-8-160 of the Employment Security Law, and having its principal place of business at , as principal, and , a surety corporation authorized by law to transact business in the State of Georgia, as surety, pursuant to the aforesaid law and in compliance therewith, are hereby held and firmly bound unto the Commissioner of Labor of the State of Georgia, and his successors in office, and unto the State of Georgia, Department of Labor, upon the conditions, hereinafter set forth, in the full sum of ($ ), for the payment of which well and truly to be made we bind ourselves, our heirs, administrators, executors, successors and assigns jointly and severally, firmly by these presents. Signed, sealed and delivered this day of , 20 THE CONDITIONS OF THE FOREGOING OBLIGATION are such that the above named principal has been duly registered as an employer under the Employment Security Law subject to the provisions of the said Employment Security Law; NOW THEREFORE, should the said principal well and truly file all reports and otherwise timely fulfill and comply with all requirements and regulations set forth in said Employment Security Law and pay all payments in lieu of contributions due and to become due under said law, and penalties and interest assessed pursuant to said law for the period to then this obligation to be void, otherwise, of full force and effect. IN WITNESS WHEREOF, the said principal and surety have executed this instrument under their hands and seals, including the corporate seals, this day of , 20 Witnesses: (Principal) (L.S.) (L.S.) Attest: By APPROVED AS TO AMOUNT, FORM AND SURETY BY: UI Legal GEORGIA DEPARTMENT OF LABOR Countersigned by: NOTE: The official or attorney in fact signing for Surety shall attach to the original bond a certified copy of authority or power to bind the Surety. It shall show that the power is in force and effect at the time of the execution of the bond. DOL-13 (R-4/14) American LegalNet, Inc. www.FormsWorkFlow.com