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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 security number of each license <br />apolicant (person si!!llinl! the aDplication). <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. lIDs 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: (),V'fr l i <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />/ .~ S;~~ <br />. IBR/tJ1)(,t d/!iY1JS \. ~ -96 <br />, <br />.fj r' <br />5V~S /SI ..Y(, /Y. <br />J4Jbo <br />[City] <br /> <br />/IJ "IJ <br />[State] <br /> <br />J:JoJ~ <br />[Zip] <br /> <br />Applicant's Address: <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Address: <br /> <br />5Ab6!(,~ 8.1R-IJ./bll,tl.- <br /> <br />709cg Cf.J16I?V/J,ii I/O/l/J <br /> <br />ti#fMlJl"lL h1~ J:fOJ( <br />[City] [State] [Zip] <br /> <br />Business Name: <br /> <br />Federal Tax Identification Number: <br /> <br />,?J- 050$ J.. <br />Jt) - i/31 )9J ~ <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 />IO',S-~ob <br />Date <br /> <br />~ . . .. .. <br /> <br />er) <br /> <br />111 <br />