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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 />Bnsiness Tax Identification Number and the social security number of each license <br />applicant (person si!!:ninl! the application). <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 infonnation; <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 />Please supply the following information and return along with your application: <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: L I t.... ~ (' <br /> <br />PERSONAL INFORMATION: <br />Applicant's Name: J.J die "'n-. T3'$t 1<: <br /> J 0 5'-1 - ;A.. &,. <br />Applicant's Address: I CJ 'i - <br />Coo.J Pri-JPt,J s ft1;J ~P143 <br /> . <br /> [City] [State] [Zip] <br />Social Security Number: 4 >1. 'lz- & z() 9 <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: <br /> <br />-1!'t.-U'i'S <br />t}()96 - C'i-J ffrv,!/f, <br />0:;J~f",vl/lf W1.P) <br />[City] [State] <br /> <br />1::01'''' f.... . :t JOVG. <br />. <br /> <br />Business Address: <br /> <br />t2d <br />-if'R7 ~ <br />[Zip] <br /> <br />Minnesota Tax Identification Number: <br /> <br />J5'/'i/bO <br />4/-dtJf'!o'i <br /> <br />Federal Tax Identification Number: <br /> <br />If a NIinnesota Tax Identification Number is not re <br /> <br />lolltln <br />'Dat~ <br /> <br />