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<br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is <br />required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification Number and social security number of each license applicant. <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required <br />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 />2. Upon receiving this information, the licensing 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 information <br />to the Internal Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance or renewal application. <br /> <br />Please supply the following information and return along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: _T~bL( () <br /> <br />NEW [ <br /> <br />RENEWAL [Xl <br /> <br />LICENSING AUTHORITY: <br />LICENSE RENEWAL DATE: <br /> <br />City of Centerville <br /> <br />,} ~ <br />7 tz.)('1,; r <br />I ; <br />I <br /> <br />,'; 7 <br />I /, it)'] <br /> <br />BUSINESS INFORMATION: <br />CI2,^- 4" rVk~ <br />i 80 \ t1llc. . ~ <br />C~p\A.k{U~ \\~ /IYlf..) <br />[City] [State} <br />0~U26' L{~ fu <br /> <br />Business Address: <br /> <br />L,-C <br />Sf- <br /> <br />Business Name: <br /> <br />S\D3g <br />[Zip] <br /> <br />Business Telephone Number: <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />\ Full Name: QCA< \ '~v e. ~ l \~ ( <br />Title: p' ..,,- 'Iii Social Security Number: __ <br />'1... Full Name: 1<... ~ 1S v-ecl \~ ( <br /> <br /> <br />Social Security Number: <br /> <br /> <br />., ~")L.", ) ~'""""' <br />Title: Social Security Number: <br />'-"\ Full Name: , <br />Title: p ~ "" ; i' ,Y Social Security Number: <br /> <br />Business Address: <br /> <br />IF A CORPORATION: <br />Corporation Name: C e"'-.le (Mo--rt- L l~a <br />I go (. ftJA-/'h Sf- <br />C e~\efu, lle ( f'VlN ~ <br /> <br />C-~r <br />6SV 30' <br /> <br /> <br />ti 1LK <br />