CCP 08-31-1992 - Laserfiche WebLink

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* ~ REVltIUf ( , , ' I ,: ' lAAllROOM MAIlROoM ; \"\J l '2. I \991 ;' ! H} X I.; wg.{2 Form" IC-134 Minnesota Department of Revenue . Rev. 11190 Withholding Affidavit for Contractors This affidavit must be approved by the Minnesota Department of Revenue belore the State of Minnesota or any of its subdivisions can make_final payment to contractors. Comp"',Mm, F.F. JE~LICKI,INC. I M'oo''''oa!6'98~'740 1._ .--~----_._--_._- Add.." 14203 WEST 62ND STREET Moolh1'"'~"''''g''' 8-1-91 Ci~ EDEN PRAIRIE St", MINNcoo, 55346 Moothl,,",wO","dod 8-31-91 Please type or print clearly above. This will be your Total contract amount $19 519 00 mailing label for returning the completed form. , . Telephone number Amount still due: (612) 934-7272 $4300.40 ______ Did you have employees work on this project? Proiect numb_er: __ 520-019 If none, explain who did the work: YES I Proiect location:._--HORffi SNFT T TN~ A\lli' I Proiect owner: CITY OF ARDEN BILLS I Address ARDEN HIllS, MINN. , Check the box that describes your involvement in the project and fill in all information requested in that category: o Sole contractor ~ Subcontractor If you are a subcontractor, fill in the name and address of the contractor that hired you: MIDWEST ASPHALT CDRP., P.O.BOX 5477, HOPKINS, MINNNESOTA 55343 . 0 Prime Contractor If you subcontracted out any work on this project, all of your subcontractors must fiie their own IC,13( 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 or Revenu disclose pertinent information relating to this project, including sending copies of this form, o the rime contractor if I a s ntr r, an subco tractors if I am a rime contractor, and to the contracting agency. Co ilia .-- Dale I PRESIDENT 7-24-92 ,-- For certification, mail original and one copy to: innesota Department of Revenue, Business Trust Tax Section Mail Station 6610, St. Paul, MN 55146-6610, l . Certificate of Compliance with Minnesota Income Tax Withholding Law I 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 frorn_ wages paid to employees relating to contract services With the state of Minnesota and/or its subdivisions. i Signature 01 aulhorized Department ol-Reven~e official ~ ~----- Date I ~t _ " A. _~ O_n_____~~~~~... I ~ . I