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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 security number of each license <br />aoolicant (oenoo sil!oio!! the 8oplication). <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 />Please supply the following information and return along with your application: <br />TYPE OF LICENSE BEING APPLIED FOR OR RENEWED: DFF5lrLl! <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />;:ED[/J1n+1 G MIJfllL <br />'37 fI B1J%/)fV()) Dt <br />iMllf\/ frJrJ <br />[City] [State] <br /> <br />$12-2- <br />[Zip] <br /> <br />Applicant's Address: <br /> <br />Social Security Number: _ <br /> <br />BUSINESS INFORMATION: <br /> <br />Minnesota Tax Identification Number: <br /> <br />VI\'( I J^, ,,,,F> <br />....Ao'1 }'J W l.\IVUI<.... <br />7D~) 2{)1H /Ji;[ 5, <br />CiJV1tRM{jj MN <br />[City] [State] <br />/1)06/&4- <br />l7-aZCf3'L/3 <br /> <br />.5;0,5~ <br />[Zip] <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />Federal Tax Identification Number: <br /> <br />~---- <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />ro/3jtJ1 <br /> <br />ate <br /> <br /> <br />66 <br />