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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 />aDDlicant (Derson sil!Dine the aDDlication). <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 />. - -. - -- -~-- n --Please Suppry thilol1owlfig in]Onnatfonanilretum along with yourapplication: <br /> <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: l, ~u ~ a <br />, <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />5';$~ Ie <br /> <br />Applicant's Address: <br /> <br />M/II1~ <br /> <br />? ~ 9 8' ~ Ce,J Ifr''t/II/€ <br />C"f-,J hI"'; ,I If <br />[City] <br /> <br />;11,./ <br />[State] <br /> <br />Social Security Number: _ <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />J~11v ~ ~r/V~f <br />tJ/JfS'" Cf.,..;hrh//' <br />C~/frilll/t /JI~ <br />[City] [State] <br /> <br />Business Address: <br /> <br />()J <br />:f5~38' <br />[Zip] <br /> <br />~. <br />IV <br />f~,tJ3 $ <br />[Zip] <br /> <br />Minnesota Tax Identification Number: <br /> <br />J5/9/atJ <br />JjI-/J~7 ;?cJ7' <br /> <br />Federal Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not req <br /> <br />J tJ /:11 JP5" <br />, Dite <br /> <br /> <br />(~.) <br /> <br />Signature and P, sition (Officer, Owner, Partner) <br /> <br />Fe? <br />