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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 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 return along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: IJJll.s~U hilJlO.f <br /> <br />NEW IX] <br /> <br />RENEWAL [ ] <br /> <br />LICENSING AUTHORITY: <br /> <br />City of CenteIVille <br /> <br />LICENSE RENEWAL DATE: <br /> <br />Business Name: <br /> <br />BUSINESS INFORMATION: <br />5Abe;J [fAR- jI/~ 6(ljtL <br /> <br />Business Address: "70 9~ Ct:,"r((;f finLi ,.f 0 <br />C fNt1i? Ii' u..f, <br />[City] <br /> <br />)1IJ J~1J [ <br />[State] <br /> <br />_J:fL1J8 <br />[Zip] <br /> <br />Business Telephone Number: 65 j - 6. ~ ,1 - 7 7 9 L <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name: -(l1?Il AIJ{ [ j;q;t1/S SA-U/{ <br />Tide: Hi l51IJti'\rr <br /> <br />, <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <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: SA ~~IltK. tJf !41JtJ"'.; fvc. <br />Business Address: 70 9~ C fV'fU?t/i L tl. io., <br /> <br />dba SAb6RJ J3AR-/VJ' bRILL <br /> <br />/f'J <br />