2002-05-05 CC Packet - Laserfiche WebLink

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I . I CERTIFICATE OF COMPLIANCE DEPARTMENT OF REVENUE I Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax Identification Number and the social security number of each tice_ aDPlicant (person si....in.. the application). Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this infonnation: I. This infonnation may be used to deny the issuance, renewal, or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest; 2. Upon receiving this infonnation, the license authority will supply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Infonnation Agreement, the Department of Revenue may supply this infonnation to the Internal Revenue Service; 3. Failure to supply this infonnation may jeopardize or delay the processing of your license issuance. Please supply the following information and return along with your application: TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: '1:'\,,, ~t...= PERSONAL INFORMATION: Applicant's Name: Applicant's Address: Social Security Number: ~~V\~U:. I t....AN [City] [State] l4lPt -DL- 11..<61 BUSINESS INFORMATION: Business Address: 'T"""DS')<t,~......., \ ~ _ DOl't ~Y4'Ios("" '{; . lql\D lJo4-A ,'... 'i))- ~'?ul-U;...:u;. jV\oJ [City] [State] ~, Business Name: CSSo '31b [Zip] Minnesota Tax Identification Number: S1f::F.::j..,..bS 4\ -1..C"L l \as \ Federal Tax Identification Number: If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <-\, \\'" \lJ'1- Date ----"~ I r )\..-M"""'- Sign d Position (Officer, Owner, Partner)