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<br />CERTIFICATE OF COMPLIANCE <br />DEP ARTMENT 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 si~nin~ 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 iriforrnation and return along with your application: <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: L) \ G <br />PERSONAL INFORMATION: <br />Applicant's Name: ~~lJ N\~6\LL <br />Applicant's Address: \gCJb N\JA:\U ~\ . <br />C.~J\RJC\J\lUL Mu 550,3~ <br />[City] [State] [Zip] <br />Social Security Number: A1D C;O 4D.& <br />BUSINESS INFORMATION: <br /> <br />(J-RDfJL \LX(XZ ~:h <br />\990 [\I\~\"J -ST. <br />~(SLV l '-L-fL (V\.I\) 3503~ <br /> <br />[ ty]\ [State] [ZIp] <br /> <br /> <br />Minnesota Tax IdentificatiA Numb;\ 1. ~l ?J Ltc;<:? <br /> <br /> <br />Federal Tax Identification N~ber: \\ t-\ \ - 101 SO CO'-- <br /> <br /> <br />\ 12J <br />If a Minnesota Tax Identification Numbe is not required e explain on th,e reverse 'de. <br />- \ <br />\ ' <br /> <br />wner,' artner) <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />SQP'T 1.~ 1/)/ Jl) <br />Date <br /> <br />