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2007-11-28 CC Packet
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2007-11-28 CC Packet
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11/21/2007 2:30:06 PM
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11/21/2007 2:29:11 PM
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<br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minneso~~tatute 270.72 Tax: Clearance: Issuance of Licenses, the licensing authority is <br />required to providClO- the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification. Nwnber and social security number of each license applicant <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required <br />to advise you of the following regarding the use of this infonnation: <br /> <br />I. 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 infonnation, the licensing authority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />Infoiniation Agreement the 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 infonnation and return along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />LICENSE lYPE: ~ NEW [ ] <br /> <br />LICENSING AUTHORI: City ofCenterville <br /> <br />~I/f/l? I <br /> <br />RENEWA~ <br /> <br />LICENSE RENEWAL DATE: <br /> <br />;l.f}otf <br /> <br />I <br />I <br />. , <br />! <br /> <br />Business Name: <br /> <br /> <br />~ <br /> <br />: I <br /> <br />Business Address: <br /> <br />Business Telephone Number: <br /> <br />?-)/-- <br /> <br />~. <br />[State] <br />Cf)b - ;LX ~ <br /> <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 />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />.7T4~ <br />
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