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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 Ideutification Number and the social security uumber 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 jeopardize or delay the processing of <br />your license issuance. <br /> <br />Applicant's Name: <br /> <br />,44.j) /i1ct~ (/}/"u <br />?I\)'ID ~~ <br />/ - ~ A/> <br />~J ~''--''''<;l. <br />[City] [State] <br /> <br />/J1AJ <br />[Zip] <br />9 7S--c' 6 - )/C;O <br /> <br />~()3Y <br /> <br />Applicant's Address: <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />AI~~ ~~~ /~ <br />, ? <br />70 q.:2 ~q <br />~ Af~ (s--0od <br />[City] [State] [Zip] <br /> <br />Business Address: <br /> <br />Minnesota Tax Identification Number: <br /> <br />:3 ~ ".1 ~ 2/ 9 <br />if I ~ /,<:J lS--, ~ C/ 7f <br /> <br />Federal Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not required, pI <br /> <br />~d.g ~7J <br /> <br />Date <br /> <br />