Print Form                 Clear form                                        BOND NO._____________
                                                                                                  TC-763WT.ai   Rev. 10/05
                              WITHHOLDING TAX SURETY BOND

KNOW ALL PERSONS BY THESE PRESENTS: That ________________________________  
__________________________________________________________ 
of (Street Address)_________________________________________________    , 
(City), County of _______________________________________    , Utah (“Principal”), and 
________________________________________    , duly certified by the Utah Department 
of Insurance (State of Utah certificate number #___________) to do business in the State of Utah, and with a rating 
of at least B+ with the A.M. Best Company, (“Surety”), are jointly and severally held and firmly bound to the people of the 
State of Utah in the sum of __________________________  Dollars ($________    ), as required 
by Title 59, Chapter 10, Part 4, Utah Code Ann. (1953, as amended), lawful money of the United States for the payment of 
which, well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly, 
severally and firmly by these presents. 

THE CONDITION OF THIS OBLIGATION IS SUCH, That

WHEREAS, the above bounden Principal has applied for a withholding tax license within the State of Utah, and that pursu-
ant to the application, a license has been or is about to be issued.

WHEREAS, a demand has been made upon the above bounden Principal by the Utah State Tax Commission 
(“Commission”) for security for the payment of withholding taxes.

NOW, THEREFORE, if the above bounden Principal shall comply with all the provisions of Title 59, Chapter 10, Part 4, Utah 
Code Ann. (1953, as amended), and in particular, pay all taxes, interest, and penalties when due, the Surety shall have no 
obligation to perform under this bond.

Upon failure of the Principal to comply with any or all of the provisions of Title 59, Chapter 10, Part 4, Utah Code Ann. (1953, 
as amended), and in particular on the Principal’s failure to pay all taxes, interest, and penalties promptly when due, and 
when demanded by the Commission, the Commission may make demand upon the surety for the payment of the amount 
of the unpaid taxes, interest, and penalties by the Principal up to, but not to exceed the amount of the Surety’s liability as 
defined by this bond, and in addition any costs or attorney’s fees incurred in collecting the same from the Surety.

This bond does not limit the liability of the Principal under Title 59, Chapter 10, Part 4, Utah Code Ann. (1953, as amended).

The Commission, through its authorized agents, reserves the right, at any time, to require a bond of greater amount than 
this bond whenever the Commission deems it necessary to comply with the provisions of Title 59, Chapter 10, Part 4, Utah 
Code Ann. (1953, as amended).

This bond shall remain in continuous force and effect until terminated as hereinafter provided.  The Surety may at any time 
terminate this bond by giving 30 days written notice by certified mail to the Utah State Tax Commission, Attention Director 
Taxpayer Services Division, 210 North 1950 West, Salt Lake City, Utah 84134.  Notwithstanding termination, this bond shall 
remain in effect for the liability that accrued or was incurred prior to the date of termination, regardless of whether the liability 
was assessed, established, known, due, or demanded by the Commission prior to the date of termination.

The provisions of this bond shall be interpreted in accordance with the laws of the State of Utah.

This bond is non-transferable.

 IN WITNESS WHEREOF, the parties have executed this bond at __________ 

__________________________ , this _____ day of _________ , 20___ .
EFFECTIVE DATE:
                                                                    By        __________________
                    Print Form                                                         Principal

          __________________
                      Surety
____________________________________                                       By __________________
 Countersignature of Resident Agent           Attorney in Fact

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                                           INDIVIDUAL ACKNOWLEDGMENT OF PRINCIPAL
STATE OF UTAH           SS
COUNTY OF ___________________
On this _____ day of ___________  , in the year 20 ___  , before me personally appeared _______________________  , to me 
known and known to me to be the person, and described in, and who executed the foregoing instrument, and acknowledgment to me that he executed the same.
(NOTARY SEAL)

                                                                                                          _______________
                                                                                                                                Notary Public

                          LLP/PARTNERSHIP OR FIRM ACKNOWLEDGMENT OF PRINCIPAL
STATE OF UTAH           SS
COUNTY OF ___________________
On this _____ day of ___________  , in the year 20 ___  , before me personally appeared _______________________  , to me 
known and known to me to be of the firm of ____________________________________________  , described in, and who 
executed the same as and for the act and deed of said firm.
(NOTARY SEAL)

                                                                                                          _______________
                                                                                                                                Notary Public

                                           CORPORATE ACKNOWLEDGEMENT OF PRINCIPAL
                                 (TO BE COMPLETED BY CORPORATION WITH CORPORATE SEAL)

STATE OF UTAH           SS
COUNTY OF ___________________
On this _____ day of ___________  , in the year 20 ___  , before me personally appeared _______________________  , to me 
known, who, being by me duly sworn, did depose and say: That he resides in _________________________________  , that he is the 
_______________________  of the  _______________  , the corporation described in and which executed the above instrument; 
that he knew the seal of said corporation, and that he signed his name thereto by like order.
(CORPORATE SEAL)                                                                             (NOTARY SEAL)

                                                                                                          _______________
                                                                                                                                Notary Public

                                 CORPORATE ACKNOWLEDGEMENT OF PRINCIPAL/LLC
                                 (TO BE COMPLETED BY LLC OR CORPORATION WITHOUT CORPORATE SEAL)

STATE OF UTAH           SS
COUNTY OF ___________________
On this _____ day of ___________  , in the year 20 ___  , before me personally appeared _______________________  , to me 
known, who, being by me duly sworn, did depose and say: That he resides in _________________________________  , that he is the 
_______________________                    of the _______________          , the corporation which executed the above instrument and which is 
described therein; that he signed the above mentioned instrument on behalf of said corporation; that he was authorized to do so.
(NOTARY SEAL)

                                                                                                          _______________
                                                                                                                                Notary Public

                                           AFFIDAVIT OF QUALIFICATION BY SURETY
STATE OF UTAH           SS
COUNTY OF ___________________
_______________________________________________ being first duly sworn, on oath deposes and says that he is the 
___________________________  of said company, and that he is duly authorized to execute and deliver the foregoing obligations; that said 
company is authorized to execute the same and has complied in all respects with the laws of Utah in reference to becoming sole surety upon bonds, undertakings 
and obligations.

Subscribed and sworn to before me
this _____ day of ___________ 20 ___
My Commission expires:  ______________                                                                    _______________
(NOTARY SEAL)                                                                                                                   Notary Public

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