2005-11-09 CC Packet - Laserfiche WebLink

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CERTIFICATE OF COMPLIANCE DEPARTMENT OF REVENUE Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax Identification Number and the social security number of each license applicant (person sienine the aoolication). Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use oftbis information: 1. This information may be used to deny the issuance, renewal, or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest; 2. Upon receiving this information, the license authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Infonnation Agreement, the Department of Revenue may supply this information to the Internal Revenue Service; 3. Failure to supply this infonnation may jeopardize or delay the processing of your license issuance. --Ple-asesupplythejollowinginformation and return alongwithyourapplication: 1YPE OF LICENSE BEING APPLIED FOR OR RENEWED: ~ PERSONAL INFORMATION: . Applicant's Address: u;;~~~ ~ Ihtfi ~{5ZJ5~ [Zip] - Applicant's Name: [City] [State] Social Security Number: BUSINESS INFORMATION: C!:-((~ 1J1~ I. r?tJ/ J11~ ~ r . C~A~~~ flu-1 J?~~ [City] [State] [Zip] Minnesota Tax Identification Number: 70 / ?..5'-S-: I '1j~ ;PI /Lf/.53~ Business Name: Business Address: Federal Tax Identification Number: If a Minnesota Tax Identification Number is not required, please explain on the reverse side. II/c;*~ Date Signature and Position (Officer, Owner, Partner) .i)~