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<br />CERTnnCATEOFCO~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 security number of each license <br />aDDlicant (Derson siP"lline: the aDDlication). <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 Departm~t 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: j);/ '}1L [ <br />PERSONAL INFORMATION: <br />Applicant's Name: ftl/J4.;1J( 1. ~~lIIf5 ~h6"1' <br />Applicant's Address: SY~5 /57 1!J :)"1'. /1/. <br />fiJ60 J/J'Jd. .6iJs'i <br />[City] '[State] [Zip] . <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name.' <br /> <br />.5A6l~ ~ )duoJf <br />7091 :JfJ ~ ;tJJf .J;;. <br />(r N1 fP,)jtt ( <br />[City] <br /> <br />mAJD <br />[State] <br /> <br />,)Jo1 i <br />[Zip] <br /> <br />Business Address: <br /> <br />Minnesota Tax Identification Number: {?7179YJ.. <br />Federal Tax Identification Number: '11- J 7lJ7fK 1 <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />/tJ-l~oJ <br />Date <br /> <br />