Kansas > Secretary Of State > Miscellaneous
Health Care Card Supplier Bond SB - Kansas
| Health Care Card Supplier Bond Form. This is a Kansas form and can be used in Miscellaneous Secretary Of State . |
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Contact Information KANSAS SECRETARY OF STATE Kansas Secretary of State SB Ron Thornburgh Health Care Card Supplier Bond Memorial Hall, 1st Floor All information must be completed or this document will not be accepted for filing. 90-01 120 S.W. 10th Avenue Topeka, KS 66612-1594 (785) 296-4564 kssos@kssos.org www.kssos.org Bond number: Bond amount: KNOW ALL PERSONS BY THESE PRESENTS, that we, Do not write in this space Name of applicant of the city of , county of , state of ,as APPLICANT, and , a corporation duly organized and existing under the laws of the state of , and aut horized to do business in the state of Kansas, as SURETY, are held and firmly boundunto the state of Kansas, in the penal sum of $50,000 lawful money of th e United States for the payment of which sum, well and trulyto be made, we bind ourselves, our heirs, executors, administrators, suc cessors, and assigns, jointly and severally, firmly by thesepresents. The condition of this obligation is such that: Whereas, , APPLICANTt to the provisions of the Kansas Health, is subjecDiscount Card Act, 2002 Session Laws Ch. 182 (the Act); NOW , THEREFORE, if the above bounden Applicant shall faithfully comply with the provisions of the Act, as amended, and the orders legally made pursuant thereto, then and in that event the foregoi ng obligation shall be void, otherwise to remain in full force andeffect. PROVIDED, HOWEVER, AND UPON THE FOLLOWING EXPRESS CONDITIONS: That any person or the attorney general claiming against the bond for a violation of the Act occurring during the time period duringwhich this bond is in effect may maintain an action at law against the APPLICANT and against the SURETY. The aggregate liability ofthe SURETY to all persons damaged by violations of the Act may not exceed the amount of the surety bond. FURTHER, this bond is executed by the SURETY upon the express condition that the said SURETY, may, if it shall so elect, cancel said bond by giving notice in writing to the Kansas Secretary of States office, and the said bond shall be deemed cancelled at the endof sixty (60) days. In the case of such cancellation by the SURETY, no further obligation shall be incurred under this bond after theexpiration of said sixty (60) days, but the liability of the APPLICANT and SURETY shall apply as above set out as to any acts or omissions which may have occurred prior to the effective date of such cancellation. Page 1 of 2<<<<<<<<<********>>>>>>>>>>>>> 2The effective date of the bond is . Month Day Year Signed and sealed this day of , 20 . Principal name Title Signature Surety name Title Signature WITNESS/ATTEST Signature Signature Instruction Submit this form in duplicate with the $265.00 filing fee. Notice: There is a $25 service fee for all returned checks. Rev. 8/11/03 jb L. 2002, Ch 182 Page 2 of 2
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