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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 Number and social security number 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 />I. 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 />2. Upon receiving this information, the licensing anthority 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 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.:rHE DEPARTMENT OF REVENUE. <br /> <br />LICENSE TYPE: MF:J1l((;tW <br /> <br />NEW [.>'1 <br /> <br />RENEWAL [ ] <br /> <br />LICENSING AUTHORITY: <br /> <br />City of CentervilIe <br /> <br />LICENSE RENEWAL DATE: <br /> <br />BUSINESS INFORMATION: <br /> <br />Business Name: cSED~S UQUDK <br />, <br />Business Address: 101) 20"'( r I 11J~ .<;. <br />[JlVfE1(JjLi[ /11N <br />[City] [State] <br />Business Telephone Number: tK/ 42? 0671 <br /> <br />$?J,~8 <br />[Zip] <br /> <br />List of Officers or Partners (full name, title, and social security number): <br /> <br />Full Name: Y:-DrJ) IfNi & /I/lllt{J( <br />, <br /> <br />Title: 1) wtVfR Social Security Number: <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br /> <br />Full Name: <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 />IF A CORPORATION: <br />corpomtiOnName:Stf)S UbI/oF!- lIVe <br />Business Address: 7(} 9,~ <br /> <br />dba :iDS VRuoE <br />2D 1ft Ifl/t 5: Ct:M~L/Ltf./J1N S?03e <br />I <br /> <br />12 <br />