Free AU-217 - New York

New York State Department of Taxation and Finance

Assignment

For value received, (Name of taxpayer) and transfer unto the New York State Department of Taxation and Finance bond(s) of the

hereby sell, assign

for

($

), No.

.

The said bond(s), which are enclosed herewith, may be sold by you if it becomes necessary to collect payment of any amounts owed by Article(s) pursuant to Tax Law (Name of taxpayer) , interest thereon, and penalties imposed for nonpayment of such taxes that are

due from the undersigned and not paid, and the balance, if any, will be returned to the undersigned as aforesaid. Such securities are to be returned to the undersigned at such time as it becomes evident that they are no longer needed as security for the acts of the undersigned. It is understood that any interest or dividends accruing on said securities shall belong to the undersigned.

Dated (Signature of taxpayer)

Sworn to before me this day of , 20

(Notary Public)

AU-217 (5/08)