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IC•134 Minnesota Department of Revenue (Rev. 7/80) Centennial Office Building St. Paul, Minnesota 55145 Affidavit For Obtaining Final Settlement Of Contract With The State Of Minnesota And Any Of Its Political Or Governmental Subdivisions Name of Contractor or Subcontractor Total Asphalt Construction Co. Business Address 475 W. Minnehaha Avenue City, Town or Post Office St. Paul Read the instructions on the other side before completing the form. Minnesota Identification Number 8465207 !State IZip Code Minnesota 55103 Project Location So Owasso Boulevard Name of State Department of Governmental Subdivision for Which Work Was Performed City of Little Canada Address of Department or Subdivision 515 E. Little Canada Road Statement On Withholding Of Income Taxes On Wages Paid (A) Contractor or Subcontractor — If you pay or supervise the payment of persons employed on this contract or project, you are a contractor or subcontractor and should complete this section. ICity, Town or Post Office Little Canada IZip Code 55117 Project or Contract Number SAP 200 - 102 -03 Total Amount of Contract $106,485.51 Amount Still Due 35,324.27 1, Edward J. under the penalties of Kieger, Sr. (Title) (Your name) perjury and criminal liability, that as provided in Minnesota Statute President payment of the persons employed by Total Asphalt Construction Company (Contractor or subcontractor) employed by the above contractor or subcontractor were subjected to withholding as provided that all money withheld and all returns required by this section, to date, have been properly properly filed with the Commissioner of Revenue. �- r / /1,(D el (You signat declare 290.97, 1 pay or supervise the • that the wages of all employees in Minnesota Statute 290.92 and deposited or paid and all returns (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. President , declare ), Edward J. Kieger urn Sr. (Tine) (Your name) 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/47f.? a 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 subidivisions. OCT 5 1932 (Department of I }evepuel (Date) ) 4