CCP 10-09-1990 - Laserfiche WebLink

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- . Form p.JG Minnesota Department of Revenue IC~,134 ,\a1<. Withholding Affidavit for Contractors :\IUS\ . Rev. 9/89 ~~ :"" ~~j"V\ This affidavit must be approved by the Minnesota Department of Revenue before the ,~ ,~~Q ~;,-' ;~,. .V U 1::~:;;:iJ State of Minnesota or any of its subdivisions can make final payment to contraclors. ~UQl ," company name -------- Minnesota tD number Allied Blacktop 86-06-387 Address Month/year wor/( began 10503 - 89th Avenue North August 6, 1990 City Slate Zip Code I Month/year worK ended Maple Grove, MN 55369 I August 7, 1990 i Total contract amount: I 25,089.35 Telepl]one number Amount still due: ( 612) 425-0575 25,089.35 -~------ Did you have employees work on this project? Project number: 11520-011-20 , 1990 Seal Coat and Overlay If none, explain who did the work: Yes Project location: Arden HiHs Project ~_~~~r: City of Arden Hills I Address 1450 West Hwy 96 I A....;I^...... u-i".... ""'-T 1:\1:\11') Check the box that describes your involvement in the project and fill in all information requested in that category: !XI Sole contractor ..-- --~. ----- C 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'ile 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 __~d.<;lr~~_ Owner/Oftig.,?_~___ -- --- --- ------ --- .---- .- 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 lh rime contractor."f I am a subcontractor, and to an subcontractors if I am a prim~ contractor, and to the contracting agency. Co nature Title Date V. President 8-13-90 For certification, mail 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. S;go""~.n~:f~ Dale AU6 1 6 1990 --- "'._~