1 RECORDING REQUESTED BY

upper lower name

C/O Street
City, Colorado
_____________SPACE ABOVE THIS LINE FOR RECORDER’S USE___________
Written Undertaking/Surety Bond — Financial Responsibility
Form #mmv-101010-SB (Private Number was assigned)
I, upper lower name, hereinafter “the Undersigned” do hereby promise to pay “pledge”
myself as surety as follows:
Whereas: There exists a requirement in the State of Colorado pursuant to CRS 42-7-103
14(a) that drivers of motor vehicles have evidence of financial responsibility and;
Whereas: The Undersigned may operate a motor vehicle, and or may be subject to Vehicle
Code 42-7-103 14(a) and its related provisions, and;
Whereas: The Undersigned has not been able to locate any lawful money of account in
circulation (Gold or Silver coin or bullion) in this State, and;
Whereas: Public Policy as established with House Joint Resolution 192 of June 5, 1933 states
in part:
That (a) Every provision contained in or made with respect to any obligation which purports to give the obligee a right to require
payment ingold or a particular kind of coin or currency, or in an amount of money of
the United States measured thereby, is declared to be against public policy;
I have attached a PROVEN self insurance bond. The reason i am saying "proven" is that i got stopped for
expired stickers on the license plates and I showed an unfiled, notarized, original. Because it was not filed with
the county clerk, the officer gave me a ticket for "no proof of insurance". When i went to court this morning and
finally sat down with the DA chick, she asked me if i had proof of insurance and i gave her a certified copy of the
filed bond and no such provision shall be contained in or made with respect to any
obligation hereafter incurred. Every obligation, heretofore or hereafter
incurred, whether or not any such provision is contained therein or made
with respect thereto, shall be discharged upon payment, dollar for dollar,
in any coin or currency which at the time of payment is legal tender for
public and private debts. Any such provisions contained in any law
authorizing obligations to be issued by or under authority of the United
States, is hereby repealed:
Form # _____________ Page 1 of 2
Now therefore and in consideration thereof, the Undersigned does hereby promise to pay i.e.
undertakes, “bonds” UPPER CASE NAME'S commercial activity for the following amount: Five
Million Dollars.
In the event that any person is damaged and can demonstrate a bona fide claim of injury or
loss, the Undersigned shall discharge all obligations dollar for dollar by and through tender
of payment pursuant to public policy, HR-192.
Dated the 9th day of the 10th month, Two Thousand Nine.
___________________________________
upper lower name
Address
city, CO
Colorado Republic
Jurat
State of Colorado )
)
County of El Paso )
Subscribed and sworn to at Colorado Springs before me this ________ Day of
_____________________, A.D. 20____.
Notary public______________________
My Commission Expires: ______________
WITNESS my hand and official seal,
_________________________________________
Signature of Notary Public
Witness___________________________________
Form #