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<br />i <br /> <br />(:) <br />n <br />""""f <br />N <br />W <br />I':t <br />c= <br />c:::a <br />.... <br /> <br />CERTIFICATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br /> <br />Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance. of Licenses, the Iicensmg <br />authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota <br />Business Tax Identification Number and the soeialseeuritv number of each license <br />8Dolicant (oerson sifmm2 the 8Dolication). <br /> <br />Under the Minnesota Government Data PIactices Act and the Federal Privacy Act of 1974, we <br />are required to advise you of the following regaIding the use oftbis wonnation: <br /> <br />1. This information may be used to deny the issuance; renewal, or tlahsfuI of your <br />license In the event you owe the Minnesota Department of Revenue delinquent <br />taxes, penalties, or mterest; <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 DepartmeDt of Revenue may supply this <br />information to the Intemal 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 irformation and return along with J1UI.l1' application: <br />. TYPE OF UCENSEBEING APPLIED FOR OR RENEWED: "'~/l.-I 'fi ba-c&t:' <br />PERSONAL INFORMATION: <br />Applicant's Name:/L1, C ft.oe,/ I1)PI I Wth- <br />Applicant's Address: 'Iff 1. 6' n:l ,.,.pell/ A-w <br />~4U V /IAN <br />[City] [State] <br /> <br />5$1) 38 <br />[Zip] <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />64~ hilJc. <br />1113 A1~ <br />c",*"&47ft <br />[city] <br /> <br />A/{)) <br />[State] <br />6"'6101>> <br />f3-0g?~t{6r .,. <br /> <br />Business Address: <br /> <br />7)&4 Ct'1-16",'",~ /I~ Lt '1 f/IlteJ <br /> <br />, <br /> <br />,4., s.",1f. <br /> <br />S1138' <br />[Zip] <br /> <br />Minnesota Tax Identification Number: <br />Federal Tax Identification Number: <br /> <br />If a Minnesota. Tax Identification Number Is not required, please explain on the reverse side. <br /> <br />/g--)..[j,:..pl/ . .:r ~.".~: ()b/A.V <br />Date and Position (Officer, Owner, Partner) <br />