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<br />CERTIFICATE OF COMFLIANCE <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 securitv number of each license <br />aDDlicant (person sil!nin2 the 8DDlication). <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. lbis 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 />Applicant's Address: <br /> <br />re r1 /) e n.J F 1JA-u pILI?. ffe e..J C. <br />. <br /> <br />689J (le/1Je.riJ1UE ~O <br />C'e/Ttf-.rllll"..e m IV 55'"d :s B <br />[City] [State] [Zip] <br /> <br />Applicant's Name: <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Address: <br /> <br />715 cp- <br />a J1f<ert/;u"C: <br />[City] <br /> <br />UJISC6'u'vr ~l714 <br />/ . <br /> <br />?# /We- <; <br />~S'ct?R <br />[Zip] <br /> <br />IJJ~ <br /> <br />Business Name: <br /> <br />ItIrJ <br />(State] <br /> <br />Minnesota Tax Identification Number: 4.5 ~ q 70 <br />Federal Tax Identification Number: c..; 1- / 95" (J 7.1 Y <br /> <br />j(j-z>-ok <br />t Date <br /> <br /> <br />If a Minnesota Tax Identification Number is not ,., <br /> <br />~o <br />