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2003-11-12 CC Packet
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2003-11-12 CC Packet
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<br />CERTIFICATE OF COMPLIANCE <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 />applicant (person sil!llinl! 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 followilig 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: / IJ /;A ~ t!./J <br /> <br />-.JJq 11 '-'CE "L .~),'/) <br />/1l/;;. cC tidy ~J. <br />/hsi> n1 s /fJ1I! <br />[City] [State] <br />Social Security Number: q 1.5 - 56 - 0 C; lCJ <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />Applicant's Address: <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />sstJ:3 3 <br />[Zip] <br /> <br />7~m 7httl11h 4"d jl)J8flhls,Z;,;?'lJ <br />/J?tJ/ ;1),(J)n:rt <br />& rr!t:R /J / J IC' IJJ fIi <br />[City] [State] <br /> <br />"S'S03?'" <br />[Zip] <br />()f) -9rJ7.J /; 7J- <br />'11-tJt11 S ~ tj <br /> <br />Minnesota Tax Identification Number: <br /> <br />Federal Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not <br /> <br />It'Plft3 <br /> <br />Date <br /> <br /> <br />reverse side. <br /> <br />,~~ <br /> <br />ture and Position (Officer, Owner, Parlner) <br />
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