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<br />. <br /> <br /> <br />.~~ <br />Fonn ,', . 7: >.~~ <br />10.134 '~\\;)' ,. Minnesota Department of Revenue <br />'" Rev.9Ill9 Withholding Affidavit for Contractors <br /> <br />. This affidavit must be approved by the Minnesota Department of Revenue before the <br />State of Minnesota or any of its subdivisions can make final payment to contractors. <br />~ rwne MIn~IOnurri:Mtr <br />Bituminous Consulting & Contracting Co., Inc. 6636955 <br />Ad<hA MOI'll'I'Vy"'wortt~ <br />2456 Hain Street N. E. 07/90 <br />City S1alo Z<>Cod& Mont"'Y"''''''''''- <br />Mpls MN 55434 08/90 <br />Total CCltIll'aCt amount: <br />84,553.00 <br />TeIephtlM nulTiMf Arrount IUI d\MI: <br />(612) 755-1888 3,000.00 <br /> <br />Did you have employees wor!< on this project? yes Project number: 520~0 11-20 <br />If none. explain who did the war!<: Project location: 1990 Seal Coat & Overlay Arden Hills <br />Project owner: City of Arden Hills <br />AdM>os <br />1450 Ii. Hwv 96 Arden Hills MN 5511: <br /> <br />Check the box that descrlb8s your Involvement In the project and fill In a/llnformatlon requestad In th.t category: <br /> <br />o Sole contractor <br />o Suboontractor H you are a subcontractor, fill in the name and address of the contractor that hired you: <br /> <br /> <br /> <br />. GO Prime Contractor H you subcontracted out any work on this project, all of your subcontractors must file their own <br />IC-134 affidavits and have them certified by the Department of Revenue before you can file your <br />affidavit. For each subcontractor you had, fill in the business infonnation below, and attacn a copy <br />of each subcontractor's certnied IC.134. (If you need more space, attach a separate sheet.) <br />Business name Address OWner/Officer <br /> <br />Allied Blacktop 10503 89th Ave. N. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />I <br />I dedare that a1llnfomlaDOI1I have filled in on this Iorm is true and c:ompkHe to the best of my knowledge and belief. I authorize <br />the Department of Revenue to disclose pertinent Information relating to this pro;ea, including sending copies of this form, <br />to th& prime c:ontractof if I am a IUbc::Ontr8Ctor, and toarry 8Ubc:ontractDl'S If I am a prime contractDf, and to the contracting agency, <br />Comrw::1cw'sIAgI'MIIUr. TIUI 0<<1. <br />\"\ '\.~ ~O( >..W- ~ q \'-\ \C\~ <br /> <br />For certification, mail to: - <br />Minnesota Department of Revenue, Business Trust Tax Section <br />Mail Station 6610, St. Paul, MN 55146-6610 <br /> <br />Certificate of Compliance w"h Mlnnel!Ota Income Tax W"hholdlng Law <br />. Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certnicate has <br />fu~iIIed all the requirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota Income tax from <br />wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions, <br /> <br />S.nM!:t~~ 0.. <br />/:). l\"-J SFP 0 6 1!~9 . <br /> <br /> <br />-------------- <br />