CCP 08-31-1992 - Laserfiche WebLink

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l~_ -'L. 1& REVENUE ;i;"..,,-JOM .f'.. MAILROOJ-J . I . 1 04 taM AUG ~'1 Form NOV 1 ::; 1991 , 1 IC-134 . Mmnesota Department of Revenue ~ Re"9189 Withholding Affidavit for Contractors ; . This affidavit must be approved by the Minnesota Department of Revenue before the t State of Minnesota or any of its subdivisions can make final payment to contractors. I Company name I Minnesota ID number METRO CURBING, INC. I 7349853 Address Month/year work began 8015 Grand Avenue South 10-1-91 City State Zip Code Month/year work ended Mpls Mn 55420 11-1-91 Total contract amount: 25,136.00 Telephone number Amount still due: ( 612 ) 881-8924 25,136.00 Did you have employees work on this project? Yes ,. Project number: SAP 187-106-01 If none, explain who did the work: Project location: North SBe.Ll~ng Ave & Project owner: Ci 1:Y of Arden Hills, r-ln Address 1450 West Highway 96 Arden Hills 55112 Check the box that describes your involvement in the project and fill in all information requested in that category: o Sole contractor XXI Subcontractor if you are a subcontractor, fill in the name and address of the contractor that hired you: MIDWEST ASPHALT CORPORATION BOX 5477 Hopkins. Mn 55343 . 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 Re...enue 10 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 to the contracting agency., Contractor's signature Metro Curbing I Title Office Mgr. Date 10-30"-91 i . i F rtification, mail to:! ota Department of Revenue, Business Trust Tax Section i Mail Station 6610, St. Paul, MN 55146-6610 * ) 'f Certificate of Compliance with Minnesota Income Tax Withhotdlng Law I . Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has .I '@fUlfilledallth.ereqUirementSOfMinnesota.Statu tes 290.92 and 290,97 concerning the withholding of Minnesota in come tax fromi wages paid to employees relating to contract services with the state of Minnesota andlor its subdivisions, I ~ NO'J "1'3 \991 : -- ~