CCP 08-31-1992 - Laserfiche WebLink

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" ~rlOt REV~ ~ . '!+ MAILROOM MAIL , ;'11';("1. 'il 4 ~VJ\' llUL 2"7_ ,,' w, l.'";{; " - )' '-'-.~ Form IC-134 Minnesota Department of Revenue . Rev. 11190 Withholding Affidavit for Contractors This affidavit must be approved by the Minnesota Department of Revenue before the State of Minnesota or any of its s~~.~Jyisions can make final paY1]1~!lt to contractors. -_.~-_...-~~ Company name F . F. JEDLICKI, INC. 1 MiM"ol' 1698~'7 40 Address 14203 WEST 62ND STREET Month/year work began 8-1-91 City EDEN PRAIRIE State MINN Code 55346 MOnlh/year work ended 8-31-91 --- , Please type or print clearly above. This will be your I TOlal contract amount: mailing label for returning the completed form. $19,519.00 _____.n._____ Telephone number Amount still due: $4300.40 (612 ) 934-7272 Did you have employees work on this project? Proiect number: 520-019 If none, explain who did the work: YES I Proiect location: NORTH <;NF:! JTNe:: .AVE , I ProiE~t owner: CITY OF ARDEN HILL.S I Address ARDEN HILLS, MINN. Check the box that describes your involvement In the project and fill in all information requested in that category: 0 Sole contractor -- ~ Subcontractor If you are a subcontractor, fill in the name and address of the contractor that hired you; MIDWEST ASPHALT CORP., P.O.BOX 5477, HOPKINS, MINNNESOTA 55343 . 0 Prime Contractor If you subcontracted out any work on this project, all of your subcontractors must file 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 of Revenu disclose pertinent information relating to this project, including sending copies of this form, a the rime contractor if I a s onl c, an subco tractors if I am a rime contraclor, and to the contractinq aqency. "" iIle Dale 7 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 ! . 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 and/or its subdivisions. ~ Signature 01 authorized Department of Revenue ollicial --------~---- .------- Date - ~--~-~ JUL ~ ~ - ..___________~._____ ____,_._ ______ n_..--.-_. ..______",,_' ',__ Slock No. ~ -