Laserfiche WebLink
STATE OF MINNESOTA, <br />Repartment of Human Services <br />Division of Licensing <br />��111111111q 11 iq� <br />1111 . ,, ,, -- f1sWES1111 <br />Under Minnesota Law (M. S. § 2,7'0.72), the Department of Human Services (DHS) and the Department of <br />Corrections are required to provide the Minnesota Commissioner of Revenue the tax identification. numbers and the <br />Social Security number olf'each license applicant. <br />Under, the Minnesota Government Data Practices Act, we must advise you that: <br />'phis information may be used to deny the 'issuance, or renewal of your license., or to revoke your license, if you <br />owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest. <br />DHS will only provide the tax, identification information to the Minnesota Department of Revenue. However, <br />under the Federal Exchange of information. Act, the Department of Revenue is allowed to supply this <br />information to the Internal, Revenue Service. <br />Failing to supply, this mifbnnation may jeopardize or delay the issuance of your license. <br />Please fill in the following information and return, this form, along with your application, to the DHS, Division of <br />Licensing. Do, not return. this, form to the Department of Revenue. <br />Please print clearly or type. <br />ignature Titlb Date <br />S <br />,e <br />PLEASE NOTE: <br />• You must provide a Social Security number, and both and Federal Tax ID numbers if you have employees. <br />• This form must be signed and dated even if you are not required to provide MN or Federal Tax ID numbers. <br />• If you have any quesbions regarding your Minnesota Business, Identification number, please contact the <br />Department of Revenue at 651-282-5225. The Department ofCorrections and Human Services are not able to <br />answer questions, regarding this information. <br />M,S-2063-ENG <br />2-05 <br />