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STATE OF MINNES�TA <br />Department af Human Services <br />Division af Licensing <br />PROOF OF MTNNESUTA TAX IDENTIFICATION INFC�RMATION <br />Under Minnesota Law (M.S. § 270.72}, the Deparkaient of Human Services (DHS) and the Department of <br />Correctians are required to provide the Minnesota Commissianer of Revenue the ta�c identification numbers and the <br />Social Security number of each license applicant. <br />Under the Minnesota Gavernment Data Practices Act, we rntist advise yau that: <br />� This information may be used ta deny the issuance, or zenewal of you�r license, or to revoke your license, if you <br />owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest. <br />■ DHS will anly provide the tax identification infortnation to the Minnesota Department of Revenne. However, <br />under the Federal Exchange of Information Act, the Department of Revenue is allawed ta supply this <br />information to the Intemal Revenue Service. <br />� Failing to supply #his information may jeopardize or delay the issuance of your license. <br />Please �ll un the fnllawing information and return this form, along with your application, to the DHS, Division af <br />Licensing. Do not return this forrn ta the Departrnent of Revenue. <br />Ple�se print clearly ar type. <br />PERSONAL 1NFORMATION: <br />l� or� �1/l l G�r��e� F - <br />� . <br />Annlicanf's Last Name: Firsi Narne M.1_ ."incial ier.uritv Nnmi�er <br />Applicant's Sireet Address: ` j City State Zip Code <br />BUSINESS INFORMATIC?N: <br />S �� II.e, L�� <br />Business Nain�: J <br />.�4 ���1� Ce.,�.�-le.,� � tol � ����(� � �� � ,�.—� i� <br />Business Street Address: City Sta.te Zip Code <br />�K �������- �� ~ �'�L� �; � <br />Minnesota Tax Identification Number �'ederal Tax Identification Number <br />Fi�l►�'"' /�1�1�1i/�]' . C��� <br />Title f Date <br />PLEASE NOTE: <br />• You must provide a Social Security nuinber, and both MN and Federal Taat ID numbers if you have employees. <br />• This form must be si�ned and dated even ifyou are not required to provide MN ar Federal Ta1c ID nurnbers. <br />• If you have any questions regarding your Minnesota Business Identification number, please conta.ct the <br />Department of Revenue at 651-282-5225. Tla�e Depart�r�ent of Corrections and Human Sezvices are noi able to <br />answex questions regaz-ding this information. <br />MS-Z063-ENG <br />z-as <br />