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MINNESOTA• REVENUE <br />This affidavit must be approved by the Minnesota Department of Revenue before the state of Minnesota or any of <br />its subdivisions can make final payment to contractors. <br />e <br />w , o <br />d <br />d <br />I <br />0 <br />�e <br />O <br />V <br />Please type or print clearly. This will be your mailing label for returning the completed form. <br />-- — — — — — — <br />Company name <br />— — — — — — — — 1 <br />Daytime phone <br />Minnesota tax ID number <br />Curb Masters, Inc. <br />Address <br />Total contract amount <br />Month /year work began <br />500 W. Poplar Street <br />$ 12,870.10 <br />October 2007 <br />city <br />State Zip Code Amount still due <br />Month /year work ended <br />Stillwater, MN 55082 -41 <br />` ------ ---- <br />f $ 12,870.10 <br />- -- --- <br />November 2007 <br />Project number <br />Project location <br />Old Mill Road, Centerville, MN 55038 <br />Project owner <br />Address city <br />State Zip code <br />City of Centerville <br />1880 Main Street, Centerville, MN 55038 <br />Did you have employees work on this project? QYes❑ No If no, who did the work? <br />Check the box that describes your involvement in the project and fill in all information requested. <br />❑ Sole contractor <br />✓❑ subcontractor <br />Name of contractor who hired you <br />Precision Excavating and Grading, LLC <br />Address <br />2104 Pierce /St/ Croix Rd, Baldwin, WI 54002 <br />❑ Prime contractor—if you subcontracted out any work on this project, all of your subcontractors must file their own IC134 <br />affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each subcontractor <br />you had, fill in the information below and attach a copy of each subcontractor's certified ICi34. If you need more space, <br />attach a separate sheet. <br />Business name <br />Address <br />Owner/Officer <br />I declare that all information 1 have filled in on this form is true and complete to the best of my knowledge and belief. I authorize the Department of Rev - <br />m enue to disclose pertinent Information relating to this project, including sending copies of this form, to the prime contractor if I am a subcontractor, and to <br />= any subcontractors If I am a prime contractor, and to the contracting agency. <br />Contractor's i - na ' tur 0 e . � Title 1� Date <br />Mail to: innesota evenue, Mail Station 6616, St. Paul, MN 55146 6610 <br />Certificate of Compliance \ <br />Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has <br />fulfilled all the requirements of Minnesota Statutes 290.92 and 270C.66 concerning the withholding of Minnesota income tax <br />from wages paid to employees relating to contract services with the state of Minnesota and /or its subdivisions. <br />Department of Revenue approval Date <br />Stock No. 5000134 (Rev. 1/07) <br />a cA r � 1�'t 1��uS�S �-o `'�y')E► L p+� X4 (� <br />20 <br />