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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 />applicant (person sil!ninl! the application). <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. 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, 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 />~~~~~-~~~ ~-Please supptythe101towi1T~infonnationCl1TdYeturn~alo"gwithJ'oura:pplication.------ - ~-~ -~~~. <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: OFf ~ A-1..t <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />)/J t & IwuA r tv ft'CnVIMV <br />'fg'fZ G~ ~ <br /> <br />t4 hi ale <br />[City] <br /> <br />MAl <br />[State] <br /> <br />-)}( z-g- <br />[Zip] <br /> <br />Applicant's Address: <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />Federal Tax Identification Number: <br /> <br />tfAkrvr ~Ie '-'1 vrlf15 <br />7()l'"3 ~-fIt k Y <br />C~4rI/;IIL.r ~ <br />[City] [State] <br />6f6tb1>> <br />g'j -0 ~ <;? )'f6~ <br /> <br />5"> p ~ i'" <br />[Zip] <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />Minnesota Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />~4 L.v~ gVf;o~ <br />SIgn ture and POSItion (Officer, Owner, Partner) <br /> <br />/0 - (I-a ~ <br />Date <br /> <br />/PI <br />