CCP 08-31-1992 - Laserfiche WebLink

Home Browse Search

'. 7' REVENUt . .I.'!o MAilROoM ~ " Form AUG 1 4 19911 IC-134 Minnesota Department of Revenue . Rev. 11/90 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. Company name A$...b~""c:...."'" Minnesota 10 number M,t.w.?s>T GI<l>. 7:2.5;<S54- Address Month/year worK began P. D. EOl-< 5.0\.77 itv"",,.,., ,qq, City Slale Zip Code Monthlyear W(lrll ended .J" ~'f "Noh:...,S f"1t--l 5~ 3-'t;, \"19:>- Please type or print clearly above. This will be your TOlal contract amount: mailing label for returning the completed form. Telephone number Amount still due: ( ) Old you have employees work on this proJect? ~ctnumber: 5.A.f. \87-\0<"-0\ 1--------- -~-- If none, explain who did the work: Proiect location: t'0<t>. S ~~I...L\.f-.lG. A \,I ~. I r. R..b€'i'J 'Hlt..{..$ Proieytowner: C\\"'( 0;= A/l.b~ Htu...c" Address A IU> I>N }-\IU-S /iJ Check the box that describes your Involvement In the project and fill In aI/Information requested In that category: 0 Sole contractor ~._~-- 0 Subcontractor If you are a subcontractor, fill in the name and address of the contractor that hired you: . [2<:J 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 f:F. -J2ht.\C"-' 'A;l1tl3 \.N. Cc.:2./o.f't. S'T- fRANK ~er:::.l..\<''''' I",,,- t:.AtoV ~"-^\.A.\~ tilJ S5il-tc. M~ SOlS;" G..,.,..A A'I:. S. CU,SI"''' I""" B ,--",...,,,,,", o.J 1-<"-' sS-"';>'t> t'>.":'. '-(""t.>& l"""c,."CA/""'" l",c. n,r., ss- L._~ bit,"" ~u sH>-> Os.;-I-1....,:, CE;;>.>TU<.- Fo.....,., l^<<.t HIv SSo~s - ~- ~---- I declare that all information I have fi.lled in on this form is true and complete to the best of my knowledge and belief. I authorize the Department of Revenue 10 disclose pertinent information relating to this project. including sending copies of this form. to the prime contractor jf I am a subcontractor, and to anv subcontractors if I am a prime contractor. and to lhe contracting agency. Contractor'ssignalure Title Dale ~ <t "C2.1? .k 0q...J B "- c..._~""'I;'1'l..el.A..~ ~ - I). -"1:>-- For certification, mail original and one copy to: Minnesota Department of Revenue, Business Trust Tax Section Mail Station 6610, SI. 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 andlor its subdivisions. 1 S~~""O"~~Mlo~R~"t"Ol ~ .i; ,- f I Stock No. 50001 . /.