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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 />--..--' <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 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 information: <br /> <br />1. This infonnation 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 FederiU Exchange of <br />Infotniation Agreement th~ 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: --=Jt> ~c..u::> NEW [J RENEWAL [)(" <br /> <br />LICENSING AUTHORITY: <br /> <br />City of Centerville <br /> <br />vN~ <br /> <br />LICENSE RENEWAL DATE: <br /> <br />Business Name: <br /> <br />BUSINESS INFORMATION: <br />~(\.O'I'- <br /> <br />l~~ <br />~..tMv=l~ <br /> <br />&P/LlS"S~ I <br />'wh ~ <b."t 'w <br /> <br />\ <br /> <br />Business Address: <br /> <br />[City] <br /> <br />fva,...} <br />[State) <br />~~\..- 42~.... ~ c,.D<<6 <br /> <br />S'SD3~ <br />[Zip) <br /> <br />Business Telephone Number: <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: ..,-;L~~... I .x;" &.. <br />Business Address: \ ~~o ""-A-,:"'> <br /> <br />r\ . 'C1 _ <br />dba '-..i"allO\'\. "-A'~S <br /><;'T... c.~;He <br />
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