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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 />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 />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 Intemal 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 return 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 />NEW[] <br /> <br />RENEWAL [)(] <br /> <br />LICENSING AUTHORITY: <br /> <br />City of Centerville <br /> <br />LICENSE RENEWAL DATE: <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />'\D <;\,~ .:S;: f\..C- . <br /> <br />"1)~Pt <br /> <br />c~ exP~~ <br /> <br />Business Address: \c,~.~:-- ~_ <br /> <br />~~\,-:..e ~ <br />[City] [State] . <br /> <br />f _C:.\ UI'lt . - _I . -012- <br />Business Telephone Number: ~J _ -, IWV' ~ <br /> <br />5~u '35 <br />[Zip] <br /> <br />List of Officers or Partners (full name, title, and social security number): <br /> <br />Full Name: rr -000 <br />Title: ~Q.~,~-\ <br />Full Nam~,. <br /> <br />, <br /> <br />",^"\.c..~~ Sn=~ <br />Social Security Number: _ <br /> <br />Title: <br /> <br />~ <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br /> <br />Social Security Number: <br /> <br />Title: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />IF A CORPORATION: <br /> <br />Corporation Name: <br /> <br />\'0 <;.\~ I :pJ\c... <br />\. ~o\O ^'" ~'-'- CS"i'-- <br /> <br />dba ~'\.sa- €)c ~-S So t' <br /> <br />Business Address: <br /> <br />.. <br />~Th'~vl L.U <br />