Free F-666-21 - Indiana

VERIFIED APPLICATION FOR RELEASE OF BOND AND CERTIFICATE OF DEPOSIT
State Form 50301 (7-01) Approved by State Board of Accounts, 2001

Department of Natural Resources / Division of Forestry

Comes now _________________________________________(Licensee) of _______________ ____________________________________________________________________________, a duly licensed Timber Buyer and, first being duly sworn upon his oath, makes this verified application to the Forestry Division, Indiana Department of Natural Resources, for release of bond and certificate of deposit; and, in support of such application deposes and says: 1. That on or about the _______ day of ________________, ______, The Licensee was issued a Timber Buyer's License pursuant to the provisions of Indiana law (I.C. 25-36.5-1-1 et seq.) 2. That the Licensee submitted to the Division of Forestry, on or about the _______ day of __________________, ________, an approved bond and bank certificate of deposit, in the amount of ____________________________________________($ ) Dollars, held at the bank know as ___________________________ of ________________________________ and made payable upon demand to the director, Indiana Department of Natural Resources, pursuant to I.C. 25-36.5-1-3. 3. That Licensee has ceased to operate or otherwise engage in activities of a Timber Buyer and now desires to terminate said License (unless otherwise previously terminated) have the said bond and certificate released. 4. That Licensee is not in violation of the Timber Buyer's Licensing Act as found in I.C. 25-36.5-1-1 et seq. and is not in default to any citizen of the State of Indiana for money due under such law. 5. That the Statements and representations are true and correct to the best of the knowledge of the undersigned, under the penalties of perjury.

In witness whereof the Licensee set his/her hand this________ day of_______________, _____. Signature_______________________ Printed Name__________________________ LICENSEE State of _________________ County of _______________ Being duly sworn upon this oath, deposes and says that he is the person who signed the above request and says all statements in the above request are true, and said statements are made for the purpose of releasing a certificate of deposit obtained to meet bonding requirements for a Timber Buyers License in the State of Indiana. Subscribed and sworn to before me, a Notary Public, this _________________ day of ____________, _________.

______________________________ NOTARY PUBLIC

My Commission Expires:______________________