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<br />CERTIFICATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />Pursuant to Minnes.ota Statute276.7?I5f!9Ibarance; lssuance of Licenses, the licensing <br />authority is required to provide t9th~.Mnwes9t!t COmmissioner of Revenue your Minnesota <br />Business Tax IdentifiCation .'.Numberandthe social security number of each license <br />applicant (personsil!ninl!the apnlication); <br /> <br />I. This information may be usedto deny the issuance, renewal, or transfer of your <br />license in the event you owe the Minnesota Department of Revenue delinquent <br />taxes, pen~Jties, or interest; <br /> <br />2. Upon receiving thi~ it1forn:~ti9n,the li<:enseauthority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal Exchange of <br />Iniormation 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 Address: <br /> <br />31i"o <br />~ <br /> <br />K,~h",[J . A. D-f fo e <br />"1<3 ti ~ <br />f~ t' ftr_ <br /> <br />[State] <br /> <br />51)'<FI '-( <br />[Zip] <br /> <br />Applicant's Name: <br /> <br />[City] <br /> <br />Social Security Number: 17 7 - 7'0 - 6 '7 j 0 <br /> <br />BUSINESS INFORMA nON: <br /> <br /> (;) A f1t h:?- <br /> -/) 'L lriH'-1l z;"r- .J.-- <br />Business Name: .,J<. <br /> [), 1).1'\, .J+ ,(jU." C-"'-f ));UI.<:tj. {.l.ut] <br />Business Address: 7 2 1t t Nfl--I"" :5rl!. {.( f <br /> ~!r-ra."tu. rl,u, 5,a 14 <br /> [City] [State] [Zip] <br /> <br />Federal T'Lt Identification Number: <br /> <br />illJ2)~~3 <br />Lit - j(Pg))J,r:; <br /> <br />Minnesota Tax Identification Number: <br /> <br />Ifa. LVlbmesot;:!: x Identijication NUl11her is not ren7J'p i. ase eXrll . 01 <br /> <br />. / /'-' <br />}2- j d I . ," . . <br />, Date Signamre and Position (Offici", Owner, Partner) <br /> <br />reverse side. <br />