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<br />10-" <br />~ <br /> <br />'IO:28AM FROM-V.,t Compan/1I1 <br />',)v 1 A UeD8rtmel1-t of Reven~e <br />. Withholding Affidavit for Contractors <br />This affldaltlt must be approvea by the Minnesof8 Department of Revenue befOTe the state of <br />MInnesota or any of Its subdMsions can make fin" payment to contractors. <br /> <br />768~428-8a~e <br /> <br />T-BIT P.002/002 <br /> <br />F-526 <br /> <br />fC..134 <br /> <br />lype <br />Or <br />Print <br /> <br /> <br />State P Code <br />MN 55374 <br /> <br />tile CCMplsted form. <br />DalYtime phone <br />763-428-2242 <br />clel COrttnlct amount <br />$218 473.40 <br />ArriOUrIt IS ue <br />S 10 873.27 <br /> <br /> <br />Project number Project locatIon <br />000816..07185-0 Centerville MN <br />Project owner d~ss <br />elt of CenteJVille 1880 Main Street <br />Dicl you heve employees work on 11\ S project? _~ YfilS _ No <br /> <br />CI1y <br />Cellterville MN <br />I no, wtJD did the WOrk? <br /> <br /> <br />Cheek the bOK that describes your invotvement In the project ana fill In all Informetion request.d. <br />Sale cantrector <br /> <br />SUbcontractor <br />Name or oonlraclor Who hlrecl you <br /> <br />Acldr... <br /> <br />7<t~ 4n~-J~ <br /> <br />dJeI~ tVt'a. ~ <br /> <br />Sign <br /> <br /> <br />7/0/ . <br /> <br />Certificate of Compliance <br />Based on records of the Minne.oOl Department of Revenue. I cattlfy that the contraetor who has ./gned this celtlflC.te he, fulfilled all the <br />requirements of Minnesota Sratutes 290.92 an~ 290.97 concerning the wlthholdin" of Minnesola Income ta1(from wages paid to employees <br />re/eting to cxmlr8ct services with the stale of Minnesota andlor its subdivisions. <br />De~ftment ofAev811w .pproval :~... ... Pi'~'~ <br />. vwa'WL t/~~.~ <br /> <br />Date <br /> <br />OCT 2 3 2008 <br /> <br />Job Number: <br /> <br />r,tock No. 5000'~. <br />I.... "11I,, <br /> <br />~ <br />