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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 securitv number of each license <br />applicant (person sil!ninl! the application). <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 />I. 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 />Please supply the following information and return along with your application: <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: kit.e~ <br />PERSONAL INFORMATION: <br />Applicant's Name: M ( C tw r ivl1/ ff//'/ <br />Applicant's Address: t{ g-9 2- C rt1~ ~ <br />()~!rlP1II fr'fN )")()]? <br />[City] [State] [Zip] <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />{I!"NT~ "'ILte- <br /> <br />lL i Vel/ <br />A~~ <br /> <br />It/l,~ / <br /> <br />Business Address: <br /> <br />1tl~ 3 :k -tJ. <br /> <br />~<1 krw~ <br />City] <br /> <br />MN <br />[State] <br /> <br />))Cl5 y- <br />[Zip] <br /> <br />Minnesota Tax Identification Number: <br /> <br />Federal Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not re uired, <br /> <br />{( -/ f . 0' <br /> <br /> <br />Date <br /> <br />Signature and Position (Officer, Owner, Partner) <br /> <br />~1 <br />'-J <br />