Gasoline Special Fuel Irrevocable Standby Letter Of Credit {MF-135}

State Form 49169 (R4 / 7-14) MF-135 Indiana Department Of Revenue Letter of Credit _____________________________________________ Applicant's Name ____________________________________________ Applicant's License Account Number Gasoline/Special Fuel Irrevocable Standby Letter of Credit Number _______________ _________________________________________ Issuing Bank Name __________________________________________ Bank FEIN __________________________________________ Effective Date ____________________________________________ Address ____________________________________________ Telephone Number ____________________________________________ Expiration Date We, _________________________________ , hereby issue an IRREVOCABLE STANDBY LETTER OF CREDIT for the Issuing Bank name of _____________________________________________________________________________, in the amount Applicant's Name and Address of $________________________ ( _____________________________ Thousand and no/100 Dollars) which is available by the Indiana Department of Revenue draft drawn at sight of ________________________________ bearing the clause Issuing Bank Name "drawn under ________________________________________ Letter of Credit for ____________________________" Issuing Bank Name Applicant's Name accompanied by this Letter of Credit and the following: Statement purportedly signed by an officer of the Indiana Department of Revenue certifying that ___________________ has been served a pre-warrant notice covering nonpayment of______________ taxes pursuant to _________________ Type of Tax Indiana Code Reference plus all applicable penalties and interest due the Indiana Department of Revenue and has failed to provide an acceptable explanation within the time period for such protests or payment of tax. A copy of the pre-warrant notice which bears the expiration date of at least five (5) days prior to the date of the draft. Drawings may be made up to an aggregate amount but not to exceed ________________________________________. Amount of Letter of Credit American LegalNet, Inc. www.FormsWorkFlow.com Unless the Indiana Department of Revenue, is notified in writing to the contrary by ______________________________ , Issuing Bank Name this Letter of Credit, the expiration date, and any future expiration dates shall automatically renew each year for additional periods of one (1) year. If_____________________elects not to renew this Letter of Credit and the expiration date thereof Issuing Bank Name (or any subsequent renewal or extension hereof), __________________ shall notify the Indiana Department of Revenue, Issuing Bank Name in writing by certified mail, at least one hundred eighty (180) days prior to the stated expiration date of the bank's election in that regard, in which event, the Indiana Department of Revenue, shall have the right thereafter until the stated expiration date to draw upon ______________________________________ in the manner above provided. Issuing Bank Name _____________________________ engages with the Indiana Department of Revenue, that all drafts drawn under Issuing Bank Name and in compliance with the terms of this Letter of Credit will be duly honored upon delivery of documents as specified if presented at ________________________________________ on or before ______________________ . Issuing Bank Address Expiration Date Except so far as otherwise stated, this credit is subject to the Customs and Practice for Documentary Credits (2007 Revision), International Chamber of Commerce Publication No. 600. IN WITNESS WHEREOF, we have hereunto set our hand and seal this _____ day of ________________ , 20 ________ . _____________________________________ Issuing Bank By: Title: _____________________________________ Officer of Bank _____________________________________ STATE OF COUNTY OF _________________________ _________________________ Before me, the undersigned, a Notary Public within and for the County and State aforesaid, this ______ day of _____________ , 20_______ personally appeared by _______________________ and acknowledged the execution of the foregoing Letter Officer of Bank of Credit. Witness my hand and seal this date ______________________ Notary Public My commission expires ________________________________ . American LegalNet, Inc. www.FormsWorkFlow.com