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<br />CERTIFICATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />. <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 />Busiuess Tax Identification Number and the social securRv number of each license <br />apolicant (oerson lIieniDI! 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 infonnation: <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 Address: <br /> <br />"16/ljUIl1((, 1Aft1/s ~5A6t1 <br />, <br /> <br />Syg~ J SJ 1) b-{~ )11, <br />JiVLO /JI)#. <br />[ ity] [State] <br /> <br />..fS DJi <br />[Zip] <br /> <br />Applicant's Name: <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />-511h6R1 (J-1IrL. /1/, hJfI/;L <br />10rg ti.,v1fJ;JtJ)I;il. !ldAO <br />tlN1f/1 VJlIt[ mill. -5' JoJg <br />[City] tState) [Zip] <br />Minnesota Tat Identification Number: g!J.. OS 0 S" <br />Federal Tax Identification Number: 30 .. Y 31783 '6 <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />If a Minnesota Tax Identification Nwnber is not re <br /> <br />Jt) -Jh,. JooJ <br />. Date <br /> <br />