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__Ft�R w FEB 0 7 1019 <br />MitDEPARTMENT <br />OF REVENUE <br />Contractor Affidavit <br />IC134 <br />This Contractor Affidavit must be certified by the Minnesota Department of Revenue before the state of Minnesota or any of its subdi- <br />visions can make final payment to contractors. For more detailed information, see the instructions on the back of this form. <br />Please type or print clearly. This information will be used for returning the completed form. <br />r Company name <br />+ Daytime phone <br />Minnesota tax ID number <br />II The Osseo Construction Co. LLC <br />( 715-533-1973 <br />'.3276708 <br />Address <br />Total contract amount <br />Month/yearwork began <br />14248 10th St., PO Box 143 <br />$ 526,300.00 <br />June 2018 <br />City State ZIP code <br />Amount still due <br />Month/year work ended <br />I Osseo WI 547582018 <br />188. `7[) <br />October 2018 <br />Project number Project location <br />3608-0.00 11221 Cummings_____P_a_rk Drive, Arden Hills, MN 55112 <br />Project owner Address <br />City <br />state ZIP code <br />Gity of Arden Hills 1245'vvest Highway 96 <br />Arden Hills <br />MN 55112 <br />Did you have employees work on this project? X Yes No If no, who did the work? <br />Check the box that describes your involvement in the project and fill in all information requested. <br />-X Sole contractor <br />— Subcontractor <br />n Name of contractor who hired you <br />Address <br />Prime contractor—If you subcontracted out any work on this project, all of your subcontractors must submit their own Contractor Affidavits <br />and have them certified by the Department of Revenue before you can submit your Contractor Affidavit. For each subcontractor you had, fill <br />in the information below and attach a copy of each subcontractor's certified Contractor Affidavit. If you need more space, attach a separate <br />sheet. <br />Busines< name Addr— Owner/Officer <br />I declare that all information I have filled in on this form is true and complete to the best of my knowledge and belief. I outIfti ize the Departmeni of Revenue to disclose pertinent <br />information relating to this project, including sending copies of this form, to the prime contractor if) am a subcontractor, and to any subcontractors if I am a prime contractor, and <br />to the contracting agency. <br />Contractor's r"u• Title Date <br />Mail to: Minnesota Rohnue, I1irWStadon 6610, St. Paul, MN 55146-6610 <br />Phone: 651-282-9999 or 1-800-657-3594 <br />Certificate of Compliance <br />Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this Contractor Affidavit has <br />fulfilled all the requirements of Minnesota Statutes 290.92 and 270C.66 concerning the withholding of Minnesota income tax from wages <br />paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. <br />Depu& I of ve ae pProvol j] 'FEY 13 101C, Dote <br />IGMSUAM <br />