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<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 Nmnber and social security nmnber 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. TIrls 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, ooder 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: ~~AC,...(JO NEW [] RENEWAL [)( <br /> <br />LICENSING AUTHORITY: City of Centerville <br /> <br />- -- - ------------UeENSERENEWALDATE:-- -------------~ LLl-~-"'_--- - -------------~---------- ___________--_m__ ----~- ------ <br /> <br />BUSINESS INFORMATION: <br />Business Name: ~fI\.O"k.. ~ Pt'2A'J ~ <br />Business Address: t't t; a t\.-\.A-'( ~ ~ \'. <br />C ~ ..sr'\~t \\.c <br /> <br /><;"So~~ <br />[Zip] <br /> <br />[City] <br /> <br />IJ\.fI.} <br />[State] <br />Cout)~ <br /> <br />Business telephone Number; <br /> <br />L,~' <br /> <br />t.{~ <br /> <br />List of Officers or Partners (full name, title, and social security number): <br />Full Name: lcoo ~M.I.~t-. <;'T\~e-.) <br />Title: '"P~o~ <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 />Full Name: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br />dba <br /> <br />~~ Gt7Lt5SS <br /> <br />11 <br />