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<br />-w <br />-----.-.-, ._~-~~'~..-.--~-_.~._----<t~~.~., ~ <br />\ ,.:"Li<OOfl, .~ <br /> <br />. ".-';:. "ilL "'-0 199Z .. '(1(;'1;1 <br />,< / Ju.) AUG 1" ~ t <br />tl'" t <br />~~';"34 Minnesota Department of Revenue' <br />Rev.91B9 Withholding Affidavit for Contractors <br /> <br />. This affidavit must be approved by the Minnesota Department of Revenue before the <br />State of Minnesota or any of its subdivisions can make final payment to contractors. J DB NO. <br />~ name ~ IOnumbel' <br />. I '7663076 <br />Central Landscaplng,lnc <br />~ ~~beQan <br />13655 Lake Drive I f\1~ Ic.CiOl <br />ClOy .... r., Code I """""-.... ondod <br />Forest Lake, MN 55025 Ylllf'F. IClC\,;l <br />I Total contracl amounl:: <br />~ Il;;1S() .(J) <br />Telephone rurtler Amou"ll stiI cbl: <br />(612) 464-2130 ___~ , ' I~O<Y-!.IO <br /> <br />Did you have employees work on this project? Project number: (, A 8 - I () \0 . 0 I <br />If none. explain who did the work: .._p,ojcct 1()C,:,i~~: ::.,g&f"""JLtlt1:",_=_AJo 5fnf QQtM1 A I <br />: _ Project owner: C.C'b.\_c.\. M ~ ~ N\ ttiJJ..o <br />] Address '-,) "1j <br /> <br />Check the box that describes your involvement in the project and fill in a1/ information requested In that category: <br /> <br />~ Sole contractor <br />- _._.~._--------- <br />15.1 Subcontractor If you are a subcontractor. fill in the name and address of the contractor that hired you: <br /> <br />rYllCQu1L':.t j1~h.CLQt ~%P-_~~o.l1~ S~T1 -t-lopJlIi\~. fYJ!L"bS 3~3 _~ <br /> <br />. 'J Prime Contractor II you subcontradled out any work on this project. all of you~ subcontractors must file their own <br />IC-134 aHidavits and have them certified by the Department of Revenue before you can file your <br />aHidavit. For each subcontractor you had. fill In the business information below. and attach a copy <br />of each subcontractors certified IC-134. (If you need more space. attach a separate sheel.) <br />B~siness name Address 9~,!,~e!/9!!ife-r~ ___~___~___. <br /> <br /> <br />---~_.. .-.~-._...._. -,-----_...-. -- <br /> <br />..-... ....... ._-_.._._-_._..._----~-- <br /> <br />,..__ __..._u.._" <br /> <br />_.._...~--. .- . -.--- .--- -.-.....---..- <br /> <br />. .-----~------ <br /> <br /> <br />I declare !hal alllnformahon I have tilled in on this lorm is true and complete to the best of my knowledge and belieL I authorize <br />the Depanment 01 Revenue disclose pertinent information relating to this project induding sending copies 01 this lorm, <br />.. _.,--___..._.1_l?__!~!! Prim(X-eC?~ _a~_or a a. ~ntr~c1or. ,a~ ,t,? a,!y..su~.':l!rac10~s. ~t I a~ap_ri.~~_O?ntr.~~~~.__~~.!_~l'!e~~r:!ract~_'!9!.I'9..:...~_ <br />. slgnatul"e Title ~' <br /> <br />ookeeper ]...R.7&<9."u_ ~ <br />P " <br />For certification. mail to: ,,' <br />Minnesota Department of Revenue. Business Trust Tax Section . <br />Mail Stalion 6610. St. Paul. MN55146.6610 <br /> <br />. Certificate of Compliance with Minnesota Income Tax Withholding Law <br />Based on records of the Minnesota Department of Revenue. I certify that the contractor who has signed this certificate has <br />fulfilled all the requirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota income tax from <br />wages paid to employees relating to contract services with the state of Minnesota andlor its subdivisions. <br />siOnah.;;;-Ora~ed-Depal'lrne;,-~;.R~~en~ ONlCtal _..n_____..____ - .__M_ ---- Dale <br /> <br />~...t. ~ u.~~~~L.~_~_~_~__ <br />