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<br />CERTWICATEOFCO~LlANCE <br />DEPARTMENT OF REVENUE <br /> <br />Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing <br />authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota <br />Business Tax Identification Number and the social securltv number of each license <br />applicant (person simine: the application). <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we <br />are required to advise you of the following regarding the use of this information: <br /> <br />1. This information may be used to deny the issuance, renewal, or transfer of your <br />license in the event you owe the Minnesota Department of Revenue delinquent <br />taxes, penalties, or interest; <br /> <br />2. Upon receiving this information, the license authority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />Information Agreement, the Department of Revenue may supply this <br />information to the Internal Revenue Service; <br /> <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your license issuance. <br /> <br />Please supply the following information and return along with your application: <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />WI {(~c.~ <br /> <br />~/~f.l~ <br /> <br />Applicant's Address: <br /> <br />JS~~()- )(torJ S~ <br /> <br />1/ IV (J () 1/ 1, r J1't,I <br />[City] [State] <br />""/- )2 - /,209 <br /> <br />56 :3{) 'I <br />[Zip] <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />e~ lIy 's <br />')~1~ - G.,.;!ertl/ IlL <br />C"/hr'h/I~ .111,,; <br />[City] [State] <br /> <br />J6r NSr <br />. <br /> <br />- <br />J, ItJ c. . <br /> <br />Business Address: <br /> <br />@ <br />~:5/)"J ~ <br />[Zip] <br /> <br />Minnesota Tax Identification Number: <br /> <br />/-5/'/~~ <br />'11- />~7$O 1 <br /> <br />Federal Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not req <br /> <br />l/)k~//)3 <br />, o'ate <br /> <br />