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<br />I <br /> <br />/- <br />I <br />, <br /> <br />1',;3-" <br />~~, ,/851 <br /> <br />Oir: 5 ... :11 N~J~ 3C~..~ .:;;.:I:"~- ::0:\ :::::::: == C;'..:I 'Ji": <br /> <br />Mlnnesoia Deo;utment o( Revenue <br />Affidavit tor Obtaining Final Settlement of Contract' with the State of <br />Minnesota and any of its Political or Governmental Subdivisions <br /> <br />ame 01 wnuat;:::;: <br /> <br />i MinneSOta lOentlflcaUOn numoer <br />r /il TIOne. rea.O lI1$uuC"JOnsl <br />I <br />I <br />I Nea COOIi! iIIlO lelecnone lIumoer <br /> <br />lus,ne.ss aQaress <br /> <br /> <br />...:1)'. lawn or poSt o:nce <br /> <br />~ State <br />1 <br />, <br /> <br />; 4:0 =e <br /> <br />, <br />, <br />i ( <br /> <br />ecl< the box wnicn aescribes your InVOIVemem In this project (read,aeiiniltOnS on omer side) <br />: ! Prime comrac-::or Ii Contractor f ; SUbconnac'tOr <br /> <br /> <br />Ole<:: Ioc.a.uon <br /> <br />. PrOW!;: or ~Irat;: numoe! <br />1 <br /> <br />} Penoo 0; CDmrae~ IMontnl're~fI <br />I <br />~ From To <br />( AmOunr stili cue <br />! <br /> <br />ame o. Mlnneso[<\ govemmerna( urm tor ....n(en won< Wi!$ oenormea <br /> <br />: T alai amount ot c:Jntrac: <br /> <br />cress ot Minnesota govemmental unit <br /> <br />: C:I)'. town at DOS; amce <br /> <br />I Zie COOe <br />! <br /> <br />,f.'d 'IOU payor suoervise ,he payment" or persons emptoyed on thIs comrac:? <br /> <br />as, did you withnold Minnesota income tax from the waaes <br />each empi9yee as required by Minnesota Statute 290.92? ~ Yes ,--; No <br /> <br />lave you filec an reauirec withhoiding returns ana deaosited Minnesota ,ax wj:;nneJd with <br />Oepar.:mem of Revenue as required by Minnesota Statutes 290.92 and 290.97? . I Yes <br /> <br />you authorize the Deoartmen, to inform the prime Gontrac,or <br />pan it's request whether your form JC- i 34 has been certified? 0 Yes U No <br /> <br />Iou are a SUQconuactor, lis, your prime contractor's business name and aadress. <br /> <br />ame: <br /> <br />Iou are a contractor or subcontractor, skip the next section of this form and sign below. <br /> <br />au are a prime conrrac.or, fill in the names anO addresses or all your SUDcomrac:ors. If you need more SDace to lis. your <br />, contractors, attach a separate sheet. Also you must attacn certified affidavits of your suOCOntraClars and sign below. <br /> <br />Yes <br /> <br />, ! <br />--' <br /> <br />No ' <br /> <br />Ii <br /> <br />No <br /> <br />re ~nd address <br /> <br />Name ana aoaress <br /> <br />. ) <br />I <br />I <br /> <br />Ime and aooress <br /> <br />Je IIno address <br /> <br />I Name ana adoress <br />I <br />I <br />J <br />j <br />( Name ana aOdress <br />I <br />, <br />{ <br /> <br />I <br /> <br />jec:are under Ine penalties of cnmtnal h,lCility lor willfully maKing a false statement. t/lar tl1e aoove sra:lemen!S are INe and cprrect Ie tne best of my <br />{~~,. 'M beH., <br /> <br /> <br />Yoar $lgr..a:t\Jm <br /> <br />Tille <br /> <br />Oat8 <br /> <br />!.!re <br /> <br />I <br /> <br />Certificate of Compliance with Minnesota Statutes 290.92 and 290.97 <br /> <br />lea an the facts stared In the above affidavIt and the iac:s In the mes and recordS of the Department ot Revenue. the aoove <br />tractorlsuocomracwr has properlY complied wIth all of the provIsIons oi Minnesota Statute 290.92 remur:g ~o the withhoiding <br />'Income tax on wages paId' to emoloyees anc Minnes01a S,alU!e 290.97 relatIng to contract seNlC2S wuh ihe St;;He 0; <br />jnesota or any of its governmentai or political SL:OdIVISlons, <br /> <br /> <br /> <br />ma;urf! 01 aUlnon.z~ DetJanmen1 0' Revenue teOfesemauve J.a.a <br />