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<br />~-- ~ <br /> <br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is <br />required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification, Nwnber and social security mnnber of each license applicant. <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, weare required <br />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 />2. Upon receiving this information, the licensing authority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />Infotn1ation Agreement tb~ Department of Revenue may supply this infonnation <br />to the Internal Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance or renewal application. <br /> <br />Please supply the following information and return along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: <br /> <br />ON. f~ t f., <br />- <br /> <br />NEW [ ] <br /> <br />RENEWAL [,)(I <br /> <br />LICENSING AUmORITY: <br /> <br />City of CentervilIe <br /> <br />LICENSE RENEWAL DATE: <br /> <br />j- ) .., Joog <br /> <br />, <br /> <br />BUSINESS INFORMATION: <br />Business Name: .5Jl6 til S 8A~ "tV ,. /;/PI bL <br />Business Address: 70'18 It.,-l.{iftlJ t" l fiO/11> <br />ttAl-lft?JILt l /)JHJ, <br />[City] [State] <br />Business Telephone Number: 651" 6 f J ,. 7791 <br /> <br />..f'J 0 J 8 <br />[Zip] <br /> <br />List of Officers or Partners (full name, title, and social security number): <br /> <br />Full Nom., ~~t( dAfI/(S .!)eJ.bC/( <br />Title: fp Is. 1 Social Security Number: <br />Full Name: <br /> <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br />Corporation Name: 5-1'"l.llkJI' 0, 1II"'''IJ0111,J~ba ~~~Lflj ftg~, 11/ ,!J/)JtL <br /> <br />Business Address: 7098 &AI1!t? V Iii" 1. ftO.flJ . <br />