1(9$'$ '(3$570(17 2) 7$;$7,21 &$5621 &,7< 1(9$'$ Taxpayer ID Date 685(7< %21' 3267(' 72 6(&85( 3(5)250$1&( 81'(5 7,7/( &KDSWHUV 377, 377A DQG % KNOW ALL MEN BY THESE PRESENTS: That we, of as principal and a surety company organized and existing under the laws of the State of business under the laws of the State of Nevada, as surety, Bond Number , , , , and authorized to do ARE HELD AND FIRMLY BOUND UNTO THE STATE OF NEVADA for its use and benefit in the penal sum of ($ ), lawful money of the United States of America, for which sum, well and truly to be paid, we bind ourselves, our heirs, executors, administrators, successors, and assigns, jointly and severally, by these presents. this day of , __________. Resident Agent Information Principal Name: ____________________________________________ Address: __________________________________________ City, State, Zip: _____________________________________ Telephone Number : _________________________________ By Principal must complete applicable acknowledgment on reverse Surety By Surety must complete affidavit of qualification on reverse *COR * BND-SUR-01.01 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 AFFIDAVIT OF QUALIFICATION (Must be completed by surety) State of _________________ ss County of _______________ On the ______________day of ______________________________ in the year, _______ before me personally appeared _________________________________________________, being first duly sworn on oath deposes and says that (s)he is the _____________________________, of said insurance company, and that (s)he is duly authorized to execute and deliver the foregoing obligation; that said insurance company is authorized to execute the same and has complied in all respects with the laws of Nevada in reference to becoming sole surety upon bonds, undertaking and obligations Notary Public Residing at [Seal] My commission expires CORPORATE ACKNOWLEDGMENT State of __________________ ss County of ________________ On the _______ day of____________ in the year _________, before me personally appeared ______________________________ to me known who, being by me duly sworn, did depose and say: That (s)he resides in _________________________________ that (s)he is the _______________________ of _____________________________ the corporation which executed the instrument on the reverse and which is described therein; that (s)he signed the instrument on behalf of the said corporation; that (s)he was authorized to do so by Article ______________ of the Articles of Incorporation of the said corporation, and by order of the Board of Directors of said corporation; and that his/her signature as it appears on the instrument is binding upon the corporation. Notary Public Residing at [Seal] My commission expires SOLE OWNER, LLC, LLP OR PARTNERSHIP ACKNOWLEDGMENT State of ____________________ ss County of __________________ On the _______ day of____________ in the year _________, before me personally appeared ______________________________ to me known who, being by me duly sworn, did depose and say: That (s)he is _________________ of _______________________, and that (s)he is duly authorized to execute on behalf of the said business the instrument on the reverse and which is described therein. Notary Public Residing at [Seal] My commission expires *COR * American LegalNet, Inc. www.FormsWorkFlow.com BND-SUR-01.01 Page 2