10-08-1980 Council Agenda - Laserfiche WebLink

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i•t34 (nrv. 7/79) nv.007(.3 -02 r.".inn''ota Department of Revenue CrnUmnial Offir.e Building St. Paul, r.4innsota 55145 Affidavit For Obtaining Final Settlement Of Contract With The State Of Minnesota And Any Of Its Political Or Governmental Subdivisions Contractor or Sttbcontractnt.% _ C Ct c T Ce) Tnn Business Address .,-._ f er, 1L, .i.-. Minnesota Identification Number 7271490 Project or Contract Number and Location 5. 233- 102 -02 South sso Boulevard Name and Address of State Department or Governmental Subdivision for Which Work Was Performed Cit-; of ?ttle C22r2da, '.:i. ^.... Total Amount of Contract S 31 (,75E Amount Still Due S 232, 27 Statement On Withholding Of Income Taxes On Wages Paid (A) Contractor or Subcontractor — If you pay or suparvse the payment of persons employed on this contract or project, you are a contractor or subcontractor and.-.should complete this section_. ... E. . n s , declare (Your name) (Tifle) under the penalties of perjury and criminal liability, that as provided in :Minnesota Statute 290.97, I pay or supervise the r 9fr Contra 1 n,,r payment of the persons employed by ?i�� %- � =' CO.r t_'.. Ct _..'_ Co. Inc. ;that the wages of all employees (Contractor or subcontractor) employed by the above contractor or subcontractor were subjected to withholding as provided in Minnesota Statute 290.92 and that all money withheld and all returns required by this section, to date, have been properly deposited or paid and all returns properly filed with the Commissioner of Revenue. p l Sept. 24, 1930 (Your signature) (Date) (B) Prime Contractor — If any portion of the above project has been subcontracted, certify below that you have received a certificate of compliance (Form IC -134) from each of the subcontractors involved. a.i. E. Neils Treasurer , declare (Your name) (Title) under the penalties of perjury and criminal liability, that as provided in Minnesota Statute 290.97, I have obtained certificates of compliance from all of my subcontractors, on this project or contract, stating that all of their employees were subjected to withholding as provided in Minnesota Statute 290.92 and that as required by this section, all money was properly deposited or paid and all returns were filed with the Commissioner of Revenue as of the date of this certification. • c �/ / Y 7' • (your s(gnature) Sent. 2'-., 1930 (Date) Certificate Of Compliance With Minnesota Statutes 290.92 and 290.97 Based on the facts stated in the above affidavit and the facts in the files and records of the Department of Revenue, I find that the above contractor (subcontractor) has, to date, properly complied with all of the provisions of Minnesota Statute 290.92 relating to the withholding of income tax on wages paid to employees and Minnesota Statute 290.97 relating to contract services with the State or any of its governmental or political subdivisions. SEP 2 5 1930 045artment of Revenue -I'. " (Date) 41