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 Number and the social security number of each license applicant (person sil!llinl! the application). Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are"required to advise you of the followilig 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 LICENSE BEING APPLIED FOR OR RENEWED: / IJ /;A ~ t!./J -.JJq 11 '-'CE "L .~),'/) /1l/;;. cC tidy ~J. /hsi> n1 s /fJ1I! [City] [State] Social Security Number: q 1.5 - 56 - 0 C; lCJ PERSONAL INFORMATION: Applicant's Name: Applicant's Address: BUSINESS INFORMATION: Business Name: Business Address: sstJ:3 3 [Zip] 7~m 7httl11h 4"d jl)J8flhls,Z;,;?'lJ /J?tJ/ ;1),(J)n:rt & rr!t:R /J / J IC' IJJ fIi [City] [State] "S'S03?'" [Zip] ()f) -9rJ7.J /; 7J- '11-tJt11 S ~ tj Minnesota Tax Identification Number: Federal Tax Identification Number: If a Minnesota Tax Identification Number is not It'Plft3 Date reverse side. ,~~ ture and Position (Officer, Owner, Parlner)