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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 Goverument 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 />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 />2. Upon receiving this information, the licensing 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 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 ~n to the agency issuing the <br />license. DO NOT RETURN TO THE DEPART~ <br /> <br />LICENSE TYPE: 0 ff SAlk <br /> <br />NEW [/] <br /> <br />RENEWAL [ ] <br /> <br />LICENSING AUTHORITY: <br /> <br />City of Centerville <br /> <br />LICENSE RENEWAL DATE: <br /> <br />BUSINESS INFORMATION: <br />Business Name: (eY}re~vt("lr{;- <br />Business Address: 70 r 3 :J tl It, <br /> <br />L, r i/"I'~ <br />Ave S. <br /> <br />Ct,? re~i/u.,t-6- <br />[City] <br /> <br />/I.1.1f) <br />[State] <br />65" /- LlU - 66 7't' <br /> <br />.5' JO 3t' <br />[Zip] <br /> <br />Business Telephone Number: <br /> <br />List of Officers or Partners (full name, title, and social security number): <br /> <br />Full Name: /111 & It tte/ <br /> <br />rh"~niJ.s <br /> <br />W4 11114.-' <br /> <br />Title: <br /> <br />Social Security Number: <br /> <br /> <br />Full Name: <br /> <br />Tide: <br /> <br />Social Security Number: <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 />COIporation Name: G J1/ I\1.J I Alt:. <br />Business Address: 7:1q J J-J"i>J AVt S <br /> <br />dba CenkrvJ!' L'1v/)"- <br />Ce n1tYViu.e ~N- S5~ ~ ~ <br />