2003-11-12 CC Packet - Laserfiche WebLink

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CERTIFICATE OF COMPLIANCE . DEPARTMENT OF REVENUE Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax Identification Numb~r and the social securitv number of each license auulicant (uerson si!min2 the auulication). Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this information: 1. This information may be used to deny the issuance, renewal, or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest; 2. Upon receiving this information, the license authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement, the Department of Revenue may supply this information to the Internal Revenue Service; 3. Failure to supply this information may jeopardize or delay the processing of your license issuance. Please supply the following information and return along with your application: .: . TYPE OF UCENSE BEING APPLIED FOR OR RENEWED: ~ <6?1 PERSONAL INFORMATION: ~ Applicant's Name: .t:;dt/l._ /l! f) /J)-rA );) tb C;JO ~ .R(J J.. J;tJO 1Aj{~s [City] Applicant's Address: /fI;U [State] ~t) if [Zip] Social Security Number: SSOO'ORMATION: ""'~~J"" Business Name: ;J2~.&c;. ~A,~ ~ .LJO'.J ~~ IV 0;2 &./e~~4 /dIJ .J.?,., &~~ /11Ll . ~fb~r - [City] [State] [Zip] 3' ~rl ~/t '-! 1- I r-.~I t, 71 Business Address: Minnesota Tax Identification Number: Federal Tax Identification Number: /12 ~ /7--03 Date If a Minnesota Tax Identification Number is not required, pl Signatme and Position (Officer, Owner, Partner)