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<br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is <br />required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification Number and social security number of each license applicant <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required <br />to advise you of the following regarding the use of this information: <br /> <br />I. 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 />2. Upon receiving this information, the licensing 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 information <br />to the Internal Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance or renewal application. <br /> <br />Please supply the following information and retmn along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: <br /> <br />J...../G. (JoR <br /> <br />NEW [ ] <br /> <br />RENEWAL [X] <br /> <br />LICENSING AUTHORITY: <br /> <br />City of Centerville <br /> <br />/-1- ,,~ <br /> <br />LICENSE RENEWAL DATE: <br /> <br />BUSINESS INFORMATION: <br />Business Name: /.AI If~ Cl y.$ (12. -z.A I N L <br />Business Address: 76 q 5 ,2CJ rH J!h/C S <br />tA", rer 1/ il.l1'" ('n rJ <br />[City] [State] <br />Business Telephone Number: "S' 1- 1.053"'/0 7 7 <br /> <br />55038" <br />[Zip] <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name: J~f\(\4i.'rn raA-NCl5 VA", o-e ~ie.ce \<... <br />Title: ftfi- $" Jt2.,It ~ Social Security Numb <br />Full Name: Ju L./~ /YJAt:l tl1" llAJ.Ja-f'R{?~ t.. <br /> <br /> <br />Social Security Number: <br /> <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br />Corporation Name: J1Iai:! 6vy!."" A2'2A- II'J~dba <br />Business Address: J () 9)' ~ ~ 1/tVr€' S <br /> <br />h/ji{, d C! '! .5 f,7,;Z, A <br />