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<br />~EVENU~
<br />. MAILROoM
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<br />Form AUG 1 4 1991
<br />IC-134 Minnesota Department of Revenue
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<br />. Re',l11<lO Withholding Affidavit for Contractors
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<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 navment to contractors.
<br />Company name A Minnesota 10 number
<br />M,t>c0=T s.J>""e-T GI<~_ 7J.S.:l.S5-'l
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<br />Address Month/year work began
<br />PD, BO)LS.-ot'f A"..".., 1"\"\\
<br />City State Zip Code Monthlyear work ended 1
<br />'NcPK"->S Mr0 5':::> 34;>' -..JuLY \C1q;;,...
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<br />Please type or print clearly above. This will be your Total contract amount:
<br />mailing label for returning the completed form.
<br />Telephone number Amount still due:
<br />( )
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<br />Did you have employees work on this project? Proiec1.J:l1.!!nP.er: S. A . ~ . \ S 7 - \ 0<.., - C I..
<br />If none, explain who did the work: Proiect location: We. 5 )..tE"\...l,..\.~G. A 1/ ~. , A ft.t.C'lV ttll..L$
<br />Proieyt owner" c: ,T"'( O'F AA.l:},E~ HtcJ_~
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<br />Address Au..,.o )-\'''-s K.J
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<br />Check the box that describes your involvement in the project and fill in all information requested in that category:
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<br />o Sole contractor
<br />o Subcontractor If you are a subcontractor, fill in the name and address of the contractor that hired you:
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<br />. t8l Prime Contractor If 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 information below, and attach a copy
<br />of each subcontractor's certified IC-134, (If you need more space, attach a separate sheet.)
<br />Business name Address Owner/Officer
<br />'4~O3. \N. <.r,.2.wll. ':>j- C
<br />'f, f -J€'t>'-Ie,,-, '1...., c. i::.,I"l:l0 hi,,..,..,.. 1'/0 5534.'" I-RAN" .J""L,L",
<br />~O\s- GAAo->~ Ave, S,
<br />M~ Cu.B''''''' It->e. 15'-'">",.,.,,,,,",,u I-<w SS'-'l;l..t:> l).oJ, '-("ut.:J(,
<br />"'.. 55 L,,+," \>ll.\VE'
<br />C<;>'>Tlv.L.. l......t>-"CA/"..". .:r-"'c. FO~___T l^",," HN %So:>'s S'u<".", Ds.'cM....:>
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<br />I declare that all information I have filled in on this form is true and complete to the best of my knowledge and belie1. I authorize
<br />the Department of Revenue to disclose pertinent information relating to this project, including sending copies of this form,
<br />10 the prime contractor ill am a subcontractor, and to any subcontractors if I am a prime contractor, and to the contracting agency.
<br />Conlracto(s signature Title Dale
<br />
<br />~ .,"e...p d< 0Q.o..Jg'\. c._.....~(..A..~ \?..\~-"":>--
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<br />For certification, mail original and one copy to:
<br />Minnesota Department of Revenue, Business Trust Tax Section
<br />Mail Station 6610, St. Paul, MN 55146,6610
<br />
<br />. Certificate of Compliance with Minnesota Income Tax Withholding Law
<br />Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has
<br />fulfilled 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. ~ ,~<\1
<br />S~na,",..',,""'ri'edDeparim.",.rR ""..~. 0 ". . ' J\ ~.G i \:late
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