Laserfiche WebLink
<br />,- <br /> <br />CERI'DICATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />Pursuant to Minnesota Statute 270.72 Tax CleaIance; Issuance of Licenses,.-the licensing <br />atttb.ority is required to provide to the Minnesota. CommiA.4lioner of Revenue your M"lIlnesota <br />Business Tax' Identification Number and the social seemitv Dumber of each license. <br />amDlieant (nerson mtmine: the amDJication). <br /> <br />Under the Minnesota Government Da1B-Practices Act and the Fedeml Privacy Act of 1974, we <br />are required to advise you of the following regaIding the use of1his information:- <br /> <br />1. This information may be used to deny the issuanoo, renewal, or trans:feJ: 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 1his <br />information to the InteImi1 Revenue Service; <br /> <br />3. Failure to supply this infOImation may jeopardize or delay the pror~ing of <br />your license issuance. <br /> <br />Please gupply the following irifonnation and return along with JI(JU1' application: <br />1YPE OF UCI!NSB BBING APPIJJlD FOR ORRJlNEWllD: ~ <br />PERSONAL INFORMATION: IJ <br />Applicant's Name: lJ2rL) /IltJ /LIlA IN <br />~ >;~ ~/UJ <br />1. 1/01) LA;(77 5 /JI/U <br />[City] rStatel 1ZiP! 55oJ/ <br /> <br />Applicant's Address: <br /> <br />Social 8,curity Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />Federal Tax Identiflcation Number: <br /> <br />;1!Ol//I/TA(,v ~ & <br />7oi2 ~~ <br />~ ~JfI)- Jll/A/ 5,-)0 <br />[City] [S1ate] [Zip] <br />3~U2/y <br />'-II /,-)Sl697 <br /> <br />. <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />Minnesota Tax ldentijicationNumber: <br /> <br />l/a- TQ%~onNumberI8 not~~_ F.[Jlain on the reverse side. <br /> <br />&cT-;;fl(JU ..fJad <br />Date -, Si~ and Position (O:fticer, Owner, ~) <br />