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CERTIFICATE OF COMPLIANCE DEPARTMENT OF REVENUE Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax Identification Number and the social security number of each license applicant (person signine the application). Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this information: 1. This information may be used to deny the issuance, renewal, or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest; 2. Upon receiving this information, the license authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement, the Department of Revenue may supply this information to the Internal Revenue Service; 3. Failure to supply this information may jeopardize or delay the processing of your license issuance. Please supply the following information and return along with your application: TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: L J9LlfJ,,/CicgfffdtC- PERSONAL INFORMATION: Applicant's Name: Applicant's Address: Social Security Number: BUSINESS INFORMATION: Business Name: Business Address: .~ichA-rdA. Ue-fZ>0 (395 0 <{CJ 4v~ r.if(~/c h'ncc; /IJ/J SL)OIV [City] [State] [Zip] L/T7 - ;O--07'S-() LJ#~L,bl'f(S "1~ 1) I mA-I' f1 CCY1tC[U;f.lc m/] [City] [State] '?:e.Ach ClJAOJ;r I :::h sz)o3f [Zip] /cJ4J LIY:3 '-11-bOj 2/ , I ~, ,)~) Minnesota Tax Identification Number: Federal Tax Identification Number: If a Minnesota Tax Identification Number is not ~red plewe explain on the reverse side. f D(.3d I DU ,.t'- I fJ-/ ~ Date Si ature and Position (Officer, Owner, Partner)