CCP 08-31-1992 - Laserfiche WebLink

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.~ ----.-.-~'\ '--..'.n---------'-:',,:ROOM! .: 'j .- /'/ 'JUL 3-01992 AUG 1 ~ ~ 'rorm 1C-134 Minnesota Department of Revenue Rev, 9189 Withholding Affidavit for Contractors . This affidavit must be approved by the Minnesota Department of Revenue before the State of Minnesota or any of its subdivisions can make final payment to contractors, JOB NO. q )-, (Q3 ~"""'" I........".,"......... Central landscaping,lnc I .7663076 AcIi:hct. ~'olIJ()tII;beoan 13655 lake Drive ; rII~ l<:t<>.~ CCy ~ ~Ccde i ~wcnet'ded Forest lake, HN 55025 Ylftf1> , lo.Cl,;/ I TOC3f~a"TWJU"'II: ~ 11,:;)S;o ,('5:) Tetephone ~ Amot.nt SfiI due; (612 ) 464-2130., ' lliC>O'-!,IO Did you have employ~ wor!< on this project? Project number: ~ S? I (l (" , 0 I If none. explain who did the wo",: ,'_ Project 1()C~ti~n: ::,.R&Jffi_1:t<lli.....:::_^JC Xni (lih";', 1 Au :_ Peolect owner: QQ_" d, . AII'~IN\ t/j,gLt..J i Address (J1) Check the box that describes your involvement in the project and fI/I in a/l information requested In that category: r:::J Sole contractor . ~ -..-. ....._.._..._._~._._u..__.____. 1\..1 Subcontractor If you are a subcontractor, fill in the name and address of the contractor fhat hired you: .Q't&ull':.t Jl~ho.,QtQCThP-_S;> Q,{1qy: S~7'1 - NopJlIi\~rtGH,_15 3~3.. . fJ Prime Contractor If you subcontra2\ed out any work on this projec!. all 01 you~ subcontractors must file their own IC-134 aHidavits and have them certified by the Department of Revenue before you can file your aHidavi!. 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 shee!.) Business n.ame Address ~f!e!/Qtfi~~r_ _.______. _._~- ---- .... .._- -......--...... ---~--~- ..-... -..... ....~._...._.__._----_._---- -.-.----...-. ~------ - --._.- - -.-...-..-- . ......--.------...- I declare lhal alllnlormation I hay filled In on lhis form is true ancr complele 10 the best Of my knowledge and belief. I authorize the Depanmenl 01 Revenue disclose perlinenl inlormalion relating 10 lhis project. induding sending copies of this form, ._ _ _.,-_...J.q..!~~ Prim91e.~~ .aft_or a a ~ntr~C'!C1r. .~~10 a~ysubC:O.ry~~a~~~~.!f I .~~ .~p_ri.~9?nl~~~~~..~J~!.h.e_~Q!racling_~~'!.9'.:.~.__ tract . $rgnature Trt\e ..,Dal .., .. ookeeper 7fR7/2.t!!i_- i For certification, mail to: } Minnesota Department of Revenue, Business Trust Tax Section 1 Mail Station 6610, Sf. Paul, MN 55146-6610 I . . 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 i 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 stale of Minnesota and/or its subdivisions, ! Signaiu.;eota~ied-OeoiIr1me':;Of'Rev~;:;eo/1lCtal ---.-.-...-.-.-- .-...-.-- ..--.--.-.. Date ; ~..t. ~~~~,~,~--~-,-- i - .