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<br />CEKl'D1CATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />PurswmttoMinnesota Statute 270.72 Tax Clea.rance; Issuan.ce of Licenses, the licensmg <br />~ is required to provide to the Minnesota Commissi~ of Revenue your Minnesota <br />Business Tax Identification Number and the soci81 securitv number of. eilehlicense <br />'aDDlieant (Berson mmunl! the aDDlication). <br /> <br />Under the Minnesota Government DataPracti.ces Act and the FedeIal Privacy Act of 1974, we <br />are required to advise you of the following regarding the use oftbiS 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 dC1inquent <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 ,:etum along with your application: <br />TYPE OF liCENSE BEING APPLIED FOR OR RENEWED: /)11!-;/ :lP4 f /8. I: / ~AI <br />PERSONAL INFORMATION: <br />~licont'sName: iA)ll~ <br /> <br />~licont's Address: <br /> <br />l~fI at) ... <br /> <br />j/.yd IJ~VfA <br />[City] <br /> <br />;:3';f.K <br />j(, e~N ~I. <br /> <br />f/1w <br />[State] <br /> <br />;'51:1'1 <br />[Zip] <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />)/t I ~ ~ J~"''''fl'' I .t4Jtt.. <br />?~? B w Ce ",1&1",,;/4 b <br />(;,,; k/*II//h /1/ ~ <br />[City] [State] <br />Minnesota Tax Identification Number: J 7'/ j / 41) <br />Federal Tax Identification Number: 'i / - I} ~ f ;f ~ f <br /> <br />/f~ ;7f1 <br />[Zip] <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />If a Mime. 'SOfa Tax Identification Number is not re~ IjeDS. e explain on the reverse side. <br /> <br />~J~~f ~~ <br />Date Signature ~ . (Officer, Owner, Partner) <br />