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 yom Minnesota Business Tax Identification Number and the social security number of each license aoolicant (oerson siPDine: the aoolication). 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 yom 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: PERSONAL INFORMATION: Applicant's Name: ~{\ f\ ~ f Vt-\rJo.Q.((.J?ee K (;!j9~ C.krerJhL-I..-e- G>n'l~p. J,,,iL" [City] !hI" [State] Ro s:r; ()3 ~ [Zip] Applicant's Address: Social Security Number: BUSINESS INFORMATION: Business Name: h!l(€ Cu y5 7095 dl.fiH Cenr(/ ill fw.1JE [City] ft?:?.,./9 ;:rife- S Jlv~ Business Address: mrl [State] 55038 [Zip] Minnesota Tax Identification Number: LIS 0 J OJ 7 0 'II,. I C;StJ 13 €-/ Federal Tax Identification Number: If a Minnesota Tax Identification Number is not required, p. ~''-I ) -- c;"3 Date lain on he reverse side. ~J/~A 19nature and Position (Officer, Owner, Partner)