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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 />aDulicant (l>erson si2nin2 the aDulication). <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. lIDs 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 />- -PleaslTsupplythlTfollowinginformation-andreturn-along-with-your-application: <br /> <br />~. <br /> <br />lYPE OF LICENSE BEING APPLIED FOR OR RENEWED: <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />f); WJ., <br />~S/D <br />~ <br />[City] <br /> <br />/ll&IVTAJfl} <br />~~~~ <br />~ 4/l/ ,--gD~ <br />[State] [Zip] <br /> <br />Applicant's Address: <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />BUffness Name: jl}tJ~;; ~~ t LJ8k <br />Business Address: 7 OZJ- Ce?-~~.(tI, Hf' <br />~ /1JV --> <)(} 7Y <br />f-Ibf [City] [State] _ [~] <br />_...fa ;;ax Identification Number: 'Ii.. - J-S. 0 i b '1 '1 <br />rfikierA Identification Number: 3 b ~ J. ')../ V <br /> <br />If a Minnesota Tax Identification Number is not required, pleas <br /> <br />J /- ;) - vS- <br /> <br />, <br />Date <br /> <br /> <br />/tfL <br />