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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 signing 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 j.eopardize or delay the processing of <br />your license issuance. <br /> <br />Please supply the following information and return along with your application: <br /> <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />UJ//'4~ <br />&33/- JVoble- <br />13. C_ <br />[City] <br /> <br />"fj/,S'sK <br />, <br /> <br />Applicant's Address: <br /> <br />~i1t.. <br /> <br />J1), <br />~5''7?9 <br />[Zip] <br /> <br />/I!~ <br />[State] <br /> <br />Social Security Number: <br /> <br />it)/ - )2 - 6 ztJ '7 <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />~ j~/ ~ <br /> <br />I <br /> <br />!JtJJa'''' t;,.,/ Itrt/" jl,. <br />(;d~/;,I/, <br />[City] <br /> <br />k:;/'d1:/ <br />. I <br /> <br />f.rJG <br /> <br />/fJ~ <br />[State] <br /> <br />RV <br /> <br />~#3~ <br />[Zip] <br /> <br />Business Address: <br /> <br />Minnesota Tax Identification Number: /5/ 7' / CJ t) <br />Federal Tax Identification Number: /i/~ )~tJ Y J ~;; <br /> <br />If a Minnesota Tax Identification Number is not re <br /> <br />rJd' ~~; tJO <br /> <br />Date <br /> <br /> <br />(~.J <br />