Fillable Printable Fuel Tax Bond
Fillable Printable Fuel Tax Bond
Fuel Tax Bond
Fuel Tax Bond Instructions
In order to qualify for a fuel tax license or to maintain your current license, you must provide proof of bond coverage. Use
this form to determine the amount of bond coverage needed and provide proof of coverage. If you have questions about
your bond requirements, please call the Fuel Tax unit at (360) 664-1852.
Complete the following table. Use your last six months of fuel activity to complete lines 1 through 6. If you do not have
actual gallon figures for this time period, estimate your volume.
If you are a licensed:
• Supplier, use the taxable distribution by fuel type.
• Distributor, use purchases by fuel type, plus any fuel imported into Washington State.
• Blender, use the taxable distribution.
Motor and Special Fuel Bonds
1. Month 1 gallons
2. Month 2 gallons
3. Month 3 gallons
4. Month 4 gallons
5. Month 5 gallons
6. Month 6 gallons
7. Total gallons for the last 6 months. (add lines 1 thru 6)
8. Monthly average (Divide line 7 by 6)
9. Monthly average liability (Multiply line 8 by <tax rate> per gallon) $
10.
Bond coverage amount (Multiply line 9 by 3)
This is your bond amount. Minimum coverage is $5,000 with a maximum of
$100,000.
$
Aircraft Fuel Bonds
1. Month 1 gallons
2. Month 2 gallons
3. Month 3 gallons
4. Month 4 gallons
5. Month 5 gallons
6. Month 6 gallons
7. Total gallons for the last 6 months (add lines 1 thru 6)
8. Monthly average (Divide line 7 by 6)
9. Monthly average liability (Multiply line 8 by <tax rate> per gallon) $
10.
Bond coverage amount (Multiply line 9 by 3)
This is your bond amount. Minimum coverage is $5,000 with a maximum of
$100,000.
$
FT-441-541 (R/12/16)WA
Click here to START or CLEAR, then hit the TAB button
Fuel Tax Bond
Give this form to your insurance company for completion, then submit the completed form:
Online - via Taxpayer Access Point (TAP) at: https://wadolprft.gentax.com/TAP/_/
By mail without payment, mail to:
Department of Licensing
Fuel Tax Unit
PO Box 9228
Olympia, WA 98507-9228
Licensee (if replacing an expired or canceled bond)
Fuel Tax License number
Please check one:
Motor and Special Fuel Tax Bond - Required for suppliers, blenders, and distributors of fuel. RCW 82.38.110 of the
Motor Vehicle and Special Fuel Tax law. Minimum coverage under this Act is $5,000, or three times the estimated
monthly tax, whichever is larger. Maximum of $100,000.
Aircraft Fuel Tax Bond - Required for distributors of aircraft fuel. RCW 82.42.040 of the Aircraft Fuel Tax law.
Minimum coverage under this Act is $5,000, or three times the estimated monthly tax, whichever is larger. Maximum
coverage is $100,000.
Insurance Company
Attorney-in-Fact for surety must personally sign bonds and riders and attach a Power-of-Attorney to all bonds and riders.
Cancellation of bond
If a bond is being canceled, the Department of Licensing must receive a written notice at least 45 days before termination.
The bond remains in effect during this time.
Let it be known that as principal,
and , a corporation authorized to transact surety business in the
state of Washington, are bound to the state of Washington in the sum of dollars for the payment of
which we, jointly and severally, bind ourselves, our heirs, executors, administrators, successors, and assigns.
The condition of this bond is that the above-named principal has applied for a fuel tax license in accordance with the
provisions of the above indicated act. This act requires security for the payments of amounts due, and which become due
from the principal under the prescribed act.
If the said principal complies with all provisions of said act, any amendments, and pays all amounts now due (which shall
be determined due under said act), then this bond shall be void; otherwise it shall remain in full force and effect.
Bond number Effective date of this bond:
Signature of principal
Signature of owner, partner, or officer of corporation. Attach Power-of-Attorney if not.
Address
(Area code) Telephone
Email
Surety
Name
Attorney-in-Fact
Agency name
Resident agent
Address
(Principal seal if incorporated) (Surety seal)
FT-441-541 (R/12/16)WA
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When you have completed this form, please print it out and sign here.
