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<br />CERTIFICATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />Dei ,o~oou> <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 aPlllication). <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: 'r; b t\. L (.>0 <br /> <br />f 0-; E. <br /> <br />~~~~ <br />[City] <br />~\"'lo- % J - :) ~ '3 4 <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />LG\I.J(\~ <br /> <br />Applicant's Address: <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />A. Kr\u:t-SOi'l <br />:;;} ,,-d <;{.. <br /> <br />A1J <br />[State] <br /> <br />5503,3- <br />[Zip] <br /> <br />Business Name: <br /> <br />TOrV'"\ \hvr"1'-b . Inc. <br />I <br /> <br />~\D 'e. Vl~ S~ <br />t\-c\~-b'r1' <br />[City] <br /> <br />Business Address: <br /> <br />Minnesota Tax Identification Number: <br /> <br />Federal Tax Identification Number: <br /> <br />rnN <br />[State] <br /> <br />SSO~3 <br />[Zip] <br /> <br />qd.l~~-l ~ <br />Lt l-09ll5S Y <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />10 >- 10 ,- 00 <br />Date <br /> <br /> <br /> <br />U <br />Signature and Position (Officer, Owner, Per) <br />