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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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<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 Tu Identification Number and the social seeuritv number of each Beense <br />aooBcsnt (oerson si2nin1! the aooBcation). <br /> <br />- under the" Minnesota GovemmentData Practices Act and the FederaI"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, p~lties, or interest; <br /> <br />2. Upon receiving this infonnation, the license authority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />Infonnation Agreement, the Department of Revenue may supply this <br />infonnation 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 your application: <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: "]; kc...D <br />PERSONAL INFORMA nON: <br /> <br />Applicant's Name: <br /> <br />~OD <s~ <br /> <br />Applicant's Address: <br /> <br />~'11(P \)Q,l~ l> fL ~ <br />~,,\. <br />(City] <br /> <br />~ <br />(State] <br /> <br />5~t>3S <br />[Zip] <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />Cna^~ ~fus~~ <br /> <br />\ 1:\'\0 ""'-"\-~~ ~ \'. <br /> <br />~\~ t\t.> <br />[City] [State] <br /> <br /><SSo3~ <br />[Zip] <br /> <br />Business Address: <br /> <br />Minnesota Tea Identification Number: <br /> <br />'"t \ 6" 'Z,c) 1-\1..0<;. \ <br />S,DS\,.o$ <br /> <br />Federal Tat Identification Number: <br /> <br />g a Mmnesota Tea Identification Numher is not re uired, <br /> <br />, ~ \ \ 0" <br />Date <br /> <br />
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