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Form Minnesota Department of Revenue , 1alt IC-134 .:_. Rev. 9/89 Withholding Affidavit for Contractors ~.~ This affidavit must be approved by the Minnesota Department of Revenue before the p..\jG 1. 4_i~9~ State of Minnesota or any of its subdivisions can make final payment to contractors. -_.._.~~ Company name Minnesota ID number J-l. Ii. s. C ON$ rRu.e T .rON; IN<:.. f)q~ ;),980 _... Month/year work began ;).3605 tOUNTi( RtJflO /0 f! PRIL }<fCjo City State Zip Code Month/year work ended L DIUiTTO; tY) A) . S535? ::T U IJE. 1'190 Tota! contract amount" b S, goD. 00 Telephone number Amount slill due: ( "J~) yg2-<Bf)lb b. g-SO. 00 Did you have employees work on this project? Project number: q 0 - 0 I ,__ If none, explain who did the work: l~rojectlocation61'l-/'Itj,.ST.I!J.IJJ.I;ROE~ ;J./,T/-t..S 5"'SJI:?, YES Project owner: c'_+,TV 0 F f} ;:1./)': N I-/Z:LLS ! Address 1'150 !!dJl'. % WESJ; /}lfOE;{) ;lzus SSJJ;l... , Check the box that describes your involvement in the project and fill in all information requested in that category: :>? Sole contractor ------ ,- -- --..-------- --- D Subcontractor If you are a subcontractor, fill in the name and address of the contractor that hired you: . 0- Prime Contractor ------_.,-~------- If you subcontracted out any work on this project, all of your subcontractors must file their own IC-134 affidavits and have them certified by the Department of Revenue before you can file your affidavit For each subcontractor you had, fill in the business information below, and attach a copy of each subcontractor's certified IC-134, (If you need more space, attach a separate sheet) Business name Address Owner/Officer ------------- ---..-- ------~--"------ 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 authorize the Department of Revenue to disclose pertinent information relating to this project, including sending copies of this form, to the prime contractor if I am a subcontractor, and__to any subcontractors if I am a prime contractor! and tOJhecon.t!acting agency. c'=1?ir" JL~~ Title Date ___ 8J.~. fS-,;{o-'1o For certification, m ,I to: Minnesota Department of Revenue, Business Trust Tax Section Mail Station 6610, St Paul, MN 55146-6610 . Certificate of Compliance with Minnesota Income Tax Withholding Law Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has fulfilled all the requirements of Minnesota Statutes 290,92 and 290.97 concerning the withholding of Minnesota income tax from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. ~,;~:p ---. Date AUG 2 4 1990 -~-'''''------'---' --, .