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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 tbe 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. 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 />Infonnation Agreement, the Department of Revenue may supply this <br />infonnation 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 />lYPE OF LICENSE BEING APPLIED FOROa8~ <br />PERSONAL INFORMATION:(i; . <br />Applicant's Name: _~L ~Ti9 j.)/ <br />Applicant's Address: ~.. D .' c~+~M fb'l7 <br />~ ~ /}fV I'S~O~ <br />[City] <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />flfIv4~41 ~~~Q, k LJM' <br />~~4,1so.~ <br />[City] [State] [Zip] <br />Minnesota Tax Identification Number: .3 ~ t 2 2/ ( <br />Lf! lr~~7 t95 <br /> <br />Business Name: <br /> <br /> <br />~J <br /> <br />Business Address: <br />, <br /> <br />Federal Tax Identification Number: <br /> <br />Date <br /> <br /> <br />If a Minnesota Tax Identification Number is not required <br /> <br />;!!j <br />