CCP 08-31-1992 - Laserfiche WebLink

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,',_ 1<- .:Ir REVENUE /i;.-,..J;,)OM-j M'llr.......,Op J 1\ ..;.....\..... .t.l-t ! . AUG 14 1992,j Form NOV 1 "3 1991 - . ~ IC-134 .. .Mlnnesota ~epartm:nt of Revenue f Rev.9/89 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 Minnesota 10 number . METRO CURBING, INC. 7349853 Address Month/year work began 8015 Grand Avenue South 10-1-91 City Stale 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 Oid you have employees work on this project? Yes ...- Project number: SAP 187-106-01 If none, explain who did the work: Project location: North Sae.Ll.lng Ave. Project owner: Cl1:Y or l\rden liJ..LJ..S, Mn 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 )(j(j 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 thaI 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 Revenue to 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 contractinQ agency. conlractor'ssignature Metro Curbing I . Title Office Mgr. Date 10-30-91 ~ . . ~ . F rtification. mail to: ' ota 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 t .@fUlfllledaUthereqUire.ments of MinnesotaStatute~ 290.92 and 290.97 concerning the withholding. of Minnesota income tax froml wages paid to employees relating to contract services With the state of Minnesota and/or Its subdiVISions. i Ii Signature of authorized Department of Revenue Date _ \9~1 i -<'/ NO'.J 13 ! ------- ~