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<br />CERTIFICATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />PursUant to Minnesota Statute 270.72 Tax Clearance; Issu3nce 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 />aDolicant (oerson sinin!! the aoolicationl. <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 oftbis 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 Revenu~ 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 />1YPE OF LICENSE BEING APPLIED FOR OR RENEWED: l'F; altLL <br /> <br />PERSONAL INFORMATION: <br /> <br />Applicant's Name: <br /> <br />)/JiclwwI r W~kfV <br />'t~fZ. G~ ~ <br />~4 JJ &J;II . <br />[City] <br /> <br />MAl <br />[State] <br /> <br />'i~1 W <br />[Zip] <br /> <br />Applicant's Address: <br /> <br />Social Security Number: <br /> <br />BUSINESS INFORMATION: <br /> <br />tMJ~ ~~ "1 w;~ <br />7 t1' , z,. .fit kt.. 5' <br />C~~IIIL J ~ <br />[city] [State] <br />Minnesota Tax Identification Number: 6 ~ -J D 1 n <br />g:~ -00 q- )'( 6 r <br /> <br />Business Name: <br /> <br />Business Address: <br /> <br />~S-P") V <br />[Zip] <br /> <br />Federal Tax Identification Number: <br /> <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br /> <br />~-;; welL ~~ <br />81 and Position (Officer, Owner, Partner) <br /> <br />/0 - (/--C f <br />Date <br /> <br />53 <br />