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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 />aoolicant (oerson silmine: the aoolication). <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. 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 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: 3A.1"L.b <br />PERSONAL INFORMATION: <br />Applicant's Name: ~1Q M.~t\a.- S~ <br />Applicant's Address: ~~ ~f.1,~ Ovt-. <br />~~\\. r\.W S'Sb) S <br />[City] [State] [Zip] <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Address: <br /> <br />[p~ ~p~S <br />--LC\Cao I\\A1P^- Sj. <br />(.j-.....~.l \. <br />[City] <br /> <br />v\i\~ <br />[State] <br /> <br />SS03 e <br />[Zip] <br /> <br />Business Name: <br /> <br />Federal Tax Identification Number: <br /> <br />'5, O~'- 0 So <br />4\ .,z..~U'-S' <br /> <br />Minnesota Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not re <br />\\\.., \O\, <br />Date <br /> <br /> <br />, g;J. <br />ition (Officer, Owner, Partner) <br /> <br />61x <br />