CCAgenda_05Sep28 - Laserfiche WebLink

Home Browse Search

• ~ STATE OF MINNL~'SOTA TAX ZD FORM • I:2CENSE APPL=CAt~IT ~QRMATIdN IIader Minnesota law (M.6.270.72), the agency issuing you this license is required to provide the MiaA.esota Commissioner of Revenue your Minnesota business tax identification and the Social Security number of each license applicant. Dnder the Minnesota Government Data Practices Act and the Federal Privaey Act of 197x, we must advise you that; + This iSSformatioa may be used to deny the issuaaae, renewal or transfer of your license if you own the Minnesota Departmeat•of Revenue delinquent taxes, penalties, or iaterestj • The licensing agency will supply it aaly to the Minnesota Department of Revenue. However, under the Federal Exchange is Iaf ormatioa Act, the Department of Revenue is allowed to supply this information to the Internal Revenue Service; • Failing to supply this information may jeopardize or delay the iseuanoe of your • ,license or processing your renewal application. Please fill ia'the follcwiag information and return 'Chia farm along with your appllicatioa to the agency issui.ug the license. Do not return to the Department of Revenue. ~~ s ~ sec ~~. ~~.~ ao~~~~~ Name of license being plied nor and license number (please print or type) _ - Q~ ~ ~ Licesis g Authority (name of city, county, or state agency issuiag license) /~~ License renewal date • Personal iziforma'tioa: Applicant s last same, First .name & iaitia •s aaareas Business Information (if a placable): social security avmbar ~~/. ~s yy~ State ., Zip Code Bus ices s acme "'-' Susuaess address City 3tats 2i~ code Mina®aota tax identification number 9'ederal tax ideatificatiea number If a Minnesota tax identification cumber is•aot required, please explain: Sigaa~ure / Tztle Date ., Z'd SL9Bir~9TS9 s~y~zaH uoate~ ~o R~i~ E~bS~80 SO IE end