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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 />applicant (person si2nin2 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 />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: T" 6.:..... v <br />PERSONAL INFORMATION: <br />Applicant's Name: {!(k'(' I 1) 13~ ler <br />Applicant's Address: JC:llt? />10/,,()') d l"r"A-; 1 <br />Ce.:n-l-e.'(' v., ,\~ }YIn ~ S-.s~.3~ <br />[City] [State] [Zip] <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />~e...Y' 'In lLr- t <br /> <br />1.8~ I mAin ~-1-. <br /> <br />~f€.l"u 'i\ \"L, 'rh.,. <br />[City] [State] <br /> <br />~-s- "':5 tfJ <br />[Zip] <br /> <br />Business Address: <br /> <br />Minnesota Tax Identification Number: 711/7 S-S/ <br />Federal Tax Identification Number: ~ () II ~ I s~-.;'l <br /> <br />If a Minnesota Tax Identification Number is not,., . d 1 as <br /> <br />IOkd-'""" c <br /> <br />. . I. <br /> <br /> <br /> <br />1:'. .. 'I ., I . . Ii IJ7,- . ,~ I . ... II <br /> <br />l . <br /> <br />the <br /> <br />'de. <br /> <br />er) <br /> <br />j;1k~ <br />