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<br />CERTIFICATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE . <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 si2nfnl! the application). <br /> <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 YO!jT application: <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: ~ <br /> <br />PERSONALINj'ORMATION: ..1) ~, <br /> <br />Applicant's Name: 'a-1/1... AI IL(7d /;1/ <br />Applicant's Address: j;,SIO ~~ U ,fl() $172- <br />~ ~. n;V S(')o3;/ <br />[City] [State] [Zip] <br /> <br />Social Security Number: <br /> <br /> <br />Business Address: <br /> <br />/V SSOJY <br />[City] [State] [Zip] <br />..3 b {; 7- 'J./R <br />L.{( I j Sr try <br /> <br /> <br />Minnesota Tat Identification Number: <br /> <br />Federal Tax Identification Number: <br /> <br />If a Mmnesota Tat Identification Number is not ,., <br /> <br />/() -~2- fl7 <br />/ Date <br /> <br />~, /', ,1tz1, , :.I. I ~, " " ~' , <br /> <br />~ <br />~ '- <br /> <br />~ :;;4 . II ..I' ,. , . ~ . " -.1 II <br />