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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 securitv number of each license <br />aDulicant (Derson si2nin2 the aODlication). <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. lbis 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 />Applicant's Name: <br /> <br />~. C_ <br />\01)0 -::51't~~ <br /> <br />\.- ~c...c> '^" tA-t ~ ~ . <br /> <br />~ ~~ \-e ~A.,) <br />[State] <br /> <br />lldi'll,;, Bt(~ <br /> <br />SO-S"O!> 2> <br />[Zip] <br /> <br />Applicant's Address: <br /> <br />[City] <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />~&~> <br /> <br />\ <br /> <br />Business Address: ~ c;c'o v4.41~ ~ .. <br /> <br />~w:~ \(. ~..,) <br />[City] [State] <br /> <br />Minnesota Tax Identification Number: c;ioc:ot..~ <br /> <br />S$o")'t> <br />[Zip] <br /> <br />Federal Tax Identification Number: <br /> <br />Lf ( -1-0'2. \ Cd; I <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />t()\ '1;.\ l~s <br />Date <br /> <br /> <br />13 <br />