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CERTIFICATE OF COMPLIANCE DEPARTMENT OF REVENUE Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota Business Tax Identification Number and the social securitv number of each license aoolicant (nerson siminl! the aoolication). Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the following regarding the use of this infonnation: I. This infonnation may be used to deny the issuance, renewal, or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest; 2. Upon receiving this infonnatiOD, the license authority will sopply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement, the Department of Revenue may sopply this information to the IntemaI Revenue Service; 3. Failure to sopply this infonnation may jeopardize or delay the processing of your license issuance. Please supply the following information and return along with your application: ._____~~~~n'PE-0F-UeENSE-BEIti(!1\i'Pl;1 i'(i1-FOB::QRR!;~'E\\lED: . PERSONAL INFORMATION: Applicant's Name: f:r-MJ) I?~ A---- / go / mcu:.-- d &~f}/Vh j;,-S03g [City] [S] [ZIp] Applicant's Address: Social Security Number: BUSINESS INFORMATION: Business Name: ~JA~.)Jf~ /'?50/ rJ1~ Jj-, ~. ~ ~!Jt?38" [City] [Stad) [Zip] Business Address: , I!c~ e~~.~ , Minnesota Tax Identification Number: Federal Tax Identification Number: If a Minnesota Tax Identification Number is not required, please explain on the reverse side. Sh~hLf Date Signature and Position (Officer, Owner, Partner)