ASSIGNMENT OF SECURITIES
IN LIEU OF SURETY BOND
AS REQUIRED BY THE VIRGINIA FUELS TAX ACT
FT 459 (11/25/2017)
This assignment, made this _______________day of ________________________, _________,
by _______________________________________________________________________________________________,
__________________________________________________________________________________________________,
__________________________________________________________________________________________________,
Assignor, to the Department of Motor Vehicles, Commonwealth of Virginia, 2300 West Broad Street, Richmond, Virginia
23220, Assignee;
WITNESSETH; That pursuant to the provisions of the Virginia Fuels Tax Act, Section 58.1-2200, et seg., Code of Virginia
(1950) as amended, in order to qualify for issuance of a license under that Act, and in lieu of filing a surety bond as required
by that Act, Assignor hereby sells, transfers, and assigns unto the Assignee, its successors and assigns, all the right, title,
and interest of the Assignor in and to the following negotiable bond(s) (which are obligations of the United States
government or of the Commonwealth of Virginia), and/or certificate(s) of deposit in a banking institution approved by the
Commissioner of the Department of Motor Vehicles:
Said bond(s) and/or certificate(s) of deposit have a principal sum of _______________________________________ dollars
($_________________) and have this day been deposited with the Department of Motor Vehicles in accordance with the
provisions of §58.1-2211 of the Code of Virginia and subject to the terms of this assignment. This assignment is made to
assure payment of any liability of Assignor to the Commonwealth of Virginia for fuels taxes due and payable, including any
and all penalties and interest accrued thereon and any damages for which Assignor may be liable by reason of his failure to
comply with any provision of the Virginia Fuels Tax Act. Full payment by Assignor of such taxes and other amounts due
under the Virginia Fuels Tax Act for the period commencing on _____________________________, _____________(Year)
and continuing for so long as Assignor is licensed under the Virginia Fuels Tax Act shall render this assignment void, but
otherwise it shall remain in full force and effect, and Assignee shall be entitled to use said bond(s) or any part thereof, or to
receive payment of said certificate(s) of deposit, for the purpose of paying any such liability of Assignor.
IN WITNESS WHEREOF, This instrument has been duly executed by the Assignor on the day and year first above written
ATTEST:
State/Commonwealth of ______________________, city or county of _____________________________
Subscribed and sworn to before me this ______________ day of ____________________, _________.
My Commission Expires __________________________ My Registration Number is: ________________________
(Year)
Year
(Name of Principal)
(President)
(Notary Public Signature and Seal)
PURPOSE: A company uses this form when submitting securities as collateral in lieu of a surety bond.
INSTRUCTIONS: Submit completed form to the Fuel Tax Unit at the above address.
(Name)
(Type of Organization, i.e. corporation, partnership, etc.)
(Address)
(Secretary)
