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<br />CER'ID'ICATE 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 ~ Commissioner of Revenue your Minnesota <br />Business Tax Identification' Number and the social' secmitv number of each license <br />apolicant (uerson sUrniDt! the 8Dulieation). <br /> <br />Under the Minne$ofa Government Data PIactices Act and the Federal Privacy Act of 1974, we <br />are required to adVise you of the following regarding the use of this iofonnauon: <br /> <br />1. This information may be used to deny the issuance, renewal, or tnmsfer 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 iriformation and return along with ymu application: <br /> <br />TYPE OF LICm~SEBE1NG APPLIED FOR OR RENEWED:. ~ ~. <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br />Applicant's Address: <br /> <br />~tl(?11-/ f flA#JD~.e.~ <br />b89~ CenteR. Ull.LK' ~-o <br />~TCfl"'~LtE tnN' . 5'So:JY <br />[City] [State] [Zip] <br /> <br />Social Security Number: _ <br /> <br />BUSINESS INFORMATION: <br />Business Name: M.s tE (; u y S RtZ z,A- <br />Business Address: 7 () q S' ;;'oqrJ ~ S <br />C'en1trV/~ rn'" SSo3Y <br />[City] [State] [Zip] <br />Minnesota Tax ldentijJcatton Number: '-/S Od} 9 7 0 <br />Federal Tax ldentljJcation Number: L/ 1- I <1S 0 1.3 Y <br /> <br />If a Minnesota Tax ldentiftcationNumber is no <br /> <br />/(J-;;;S - 0'1 <br /> <br />. <br />Date <br /> <br />