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<br /> <br />TAX CLEARANCE INFORMATION <br /> <br />TO LICENSE APPLICANT: <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authority is <br />required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax <br />Identification Number and social security number of each license applicant <br /> <br />Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required <br />to advise you of the following regarding the use of this information: <br />: ~ <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 />2. Upon receiving this information, the licensing 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 information <br />to the Internal Revenue Service. <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance or renewal application. <br /> <br />Please supply the following information and return along with your application to the agency issuing the <br />license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: tJ F f (A~ <br /> <br />NEW [ ] <br /> <br />RENEWAL [.y( <br /> <br />LICENSING AUTHORITY: City of Centerville <br />~~~~~~-~~ LIeENSE~RE-NEWAL-D.A-TE:~-II-I-I-fj'r- m~_u~ - --~-~- - ~------~ - --~ ---~- ~-----~-~-----~~~---~---~~-~ <br />BUSINESS INFORMATION: <br />Business Name: C e- fJ kvr ~ i-lIe <br />Business Address: 1tJ f3 2-0 -f1, <br />C~~r'o7(e. <br />[City] <br /> <br />LI1 v-Q~ <br />~ <br /> <br />MIl <br />[State] <br /> <br />.r,rrJ~~ <br />[Zip] <br /> <br />Business telephone Number: <br /> <br />Irf" -Lf,U -66"7 Lj <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name: JVllv~/ r W;tvM,4-L <br />Title: Ov; ~Y' Social Security Number: . <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />IF A CORPORATION: <br />Corporation Name: (; Iv A"lIV ~c . <br /> <br />dba {~~II-i..- tV7 ~ <br /> <br />Business Address: <br /> <br />&2 <br />