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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 seeuritv number of each license <br />applicant (penon si2nilU! the application). <br /> <br />. -Under the Minnesota Government Data Practices Act and the Federa"i?rivacy Act of 19.74, we <br />are r~quired 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, ~nalties, or interest; <br /> <br />2. Upon receiving this information, the license authority will supply it only to the <br />Minnesota Department ~f 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 your application: <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: fLEN6vv ITF ~ArAe <br /> <br />PERSONAL INFORMA nON: <br /> <br />Applicant's Name: <br /> <br />;t1l-f>!v.vf 7 Iff; ,.fA fl <br />'18'12- C,~ M <br />fJtklot Ie ~J\J <br /> <br />, <br />[City] [State] <br /> <br />W/lttMA?-- <br /> <br />Applicant's Address: <br /> <br />Social Security Number: <br /> <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Address: <br /> <br />()q k,~~/Ie <br />71i~3 . ~~ <br />a-/e-.r~k <br />[City] <br /> <br />L'1V~' i5~~( <br />A.e-)' <br /> <br />Business Name: <br /> <br />Federal Tax Identification Number: <br /> <br />-AMI <br />[State] <br />61/107f, <br /> <br />~~#oJ }i5Y6Y <br /> <br />5~~? <br />[Zip] <br /> <br />Minnesota Tax Identification Number: <br /> <br />If a Mmne30ta Tax Identification Number is n <br /> <br />!D.J/'7 <br />Date <br /> <br />I , I' , , <br /> <br />Signature and Position (Officer, Owner, Partner) <br />