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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 securitv number of each license <br />aoolicant (oerson si2nin2 the aoolication). <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 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 /> <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: Od S4t it t1 val <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Address: <br /> <br />'U/?RAI'J{ l JAM'S Y:11?Ci( <br /> <br />~ - <br />.Si$5 /S1/11 .57', I//. <br /> <br />Applicant's Name: <br /> <br />[~~ti) <br /> <br />/YJlti" <br />[State] <br /> <br />\~<JOcl~ <br />[Zip] <br /> <br />Social Security Number: _ <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Address: <br /> <br />'- <)Ab&l? ~ 13AIl- JV~6/?liL <br />7(} 9rt CfiVftJiJltlt A1J. <br /> <br />~ <br /> <br />[flvi'? l4Lll <br />[City] <br /> <br />111111; ~ <br />[State] <br /> <br />,s-rIJ1~ <br />[Zip] <br /> <br />Business Name: <br /> <br />Federal Tax Identification Number: <br /> <br />~ ~ - 0 s as 1- <br />~o ,A '1Ji7~dq <br /> <br />Minnesota Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />~- Alflu{1'l/1' <br />goatuIi. osition (Officer, Owner, Partner) <br /> <br />J-II ~(}6 <br />Date <br /> <br />~ <br />