Form M-219 Indiana Department of Revenue State Form 41528 (R2 / 7-11) Permit Fee Bond Surety bond given by: ______________________________________________ of ___________________________________ Name of Principal Street Address City/Town of _________________________ County of __________________ and State of ______________ as principal, and Name of City or Town ___________________________________________ Name of County Name of State of ________________________________________________________ , Name of Surety Street Address City State Zip Code as surety, to the State of Indiana in the sum of ___________________ dollars, for the payment of which we bind ourselves, our heirs, executors, administrators and assigns. The above principal has applied for, and, subject to the execution of a bond as provided by law, has obtained Quarterly Billing Authorization to move oversize loads over State and Federal Highways, as granted by the Indiana Department of Revenue in accordance with Title 9 of the Indiana Code. If the above principal, _______________________________________ , shall do and perform the things agreed by the principal in the permit and the Transporting Agreement and shall pay all permit fees, within 20 days after the end of each calendar quarter, for the movement of each oversize load moved over State and Federal Highways then this obligation shall be void, otherwise it remains in full force and effect. It is expressly understood and agreed that the liability of the Surety for any and all claims hereunder shall in no event exceed the penal sum of this obligation as herein stated. If the surety shall so elect, this bond may be canceled by giving 60 days’ written notice of such cancellation to the principal and a like 60 days’ written notice to the Indiana Department of Revenue, Motor Carrier Services Division, hereinafter referred to as the Division. Cancellation shall become effective at the expiration of 60 days from the Division’s receipt of written notice, unless a new bond is filed by such principal and approved by the Division prior to such times, in which event such cancellation shall be effective from the date of the approval of such new bond. Notice of the cancellation shall not affect the liability of the surety for any acts or omission of the principal occurring prior to the date when the cancellation shall become effective, but the surety shall continue to be liable under all of the provisions of this bond for all acts and omissions of such principal occurring prior to the cancellation to the same extent as if such notice of cancellation had not been given. The principal binds himself, his successors and assigns, upon receipt of such notice and within said period of 60 days, to prepare and file with the Division a new bond to the satisfaction and approval of said Division, in the sum required by the Division with surety to be approved by said Division. This bond is a continuing bond and shall continue in full force and effect from its effective date of ___________________________ 20________ , until cancelled in the manner set herein, or the filing of a new bond as required by the Division. IN WITNESS WHEREOF, we hereunto set our hand and seal this _______________ day of ________________, 20_____________ ________________________________________________ Principal Attest: By ______________________________________________ Owner or President __________________________________________________ ________________________________________________ Secretary of Corporation Surety By ______________________________________________ President STATE OF: ________________________________________ ________________________________________________ } ___________________________________________ COUNTY Resident Agent SS: Before me, the undersigned, a Notary Public within and for the County and State aforesaid, this _________ day of______________ 20_____, personally appeared _________________________________________________________________and acknowledged the execution of the foregoing bond. Witness my hand and seal this date _____________________________________________________________________________ Notary Public My commission expires: _______________________ American LegalNet, Inc. www.FormsWorkFlow.com