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<br />CERTIFICATE OF COMPLIANCE <br />DEPARTMENT OF REVENUE <br /> <br />PUIsuant 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 />aDPlicant (Derson sil!lline: the aDDlicatiou). <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 />I. lbis 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 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 />3. Failure to supply this information may jeopardize or delay the processing of <br /> your license issuance. <br />Please supply the following information and return along with your application: <br />TYPE OF LICENSE BEING APPLmD FOR OR RENEWED: <br />PERSONAL INFORMATION: <br />Applicant's Name: Ca-,J) P,.M.-'.--..H ..A..-- <br />Applicant's Address: /gO/ f}1~ ~l: <br /> ~/Wh !?-S03g' <br /> [(;ity] [S ] [Zip] <br />Social Security Number: _ - <br />BUSINESS INFORMATION: <br />Business Name: ~J?~~ maVt- <br />Business Address: /'60/ 1J1A-~ ff. <br /> ~ 6-5l/3!? <br /> i~ <br /> [City] [Stat6] [Zip] <br />Minnesota Tax Identification Number: ~~ <br /> , <br />Federal Tax Identification Number: e(~,~ <br /> , <br />If a Minnesota Tax Identification Number is not required, please explain on the reverse side. <br />Sh.~;;Ef <br />Date Signature and Position (Officer, Owner, Partner) <br /> <br />, <br />