10-26-1988 Council Agenda - Laserfiche WebLink

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tMv. new F `' OCT 13 13,6 Minnesota and any of its Political or Governmental Subdivisions Minnesota Department of Revenue Affidavit for Obtaining Final Settlement of Contract with the State of EOCT 1 4 198a 180'5166ss Trust Ta* Name of contractor t f"Iti. N1f_"SarA 4-tcm6 C Business address Ir}3 W . 2)12..tct - -st 13- fox 322 City, town or post office CDWFcCOf3t 3A Check the box which describes your involvement in this project (read definitions on other side) Prime contractor ❑ Contractor ❑ Subcontractor State MN Minnesota identification number (if none, read instructions) 44642-07 Zip code 6t60 Area code and telephone number (507 ) LF55- 3SS 3 yg- Project location 6CLA,tr.-Cep-cc-2 - 433 G. Lt- rrueC/ Roy 2b. Name of Minnesota governmental unit for which work was performed C(-1-N4 of 1 -rrnE. CANAIDA Address of Minnesota governmental unit '5 5 5 . LL TR CANAr- (Lb Project or contract number S'1 -15 Period of contract (Month /Year) From 588 To rain 127 Total amount of contract Amount still due tf-75 City, town or post office LI-rn e CAtAt A Zip code 55115 Did you pay or supervise the payment of persons employed on this contract? Yes ❑ . No If yes, did you withhold Minnesota income tax from the wages ❑ No of each employee as required by Minnesota Statute 290.92? . Yes Have you filed all required withholding returns and deposited Minnesota tax withheld with the Department of Revenue as required by Minnesota Statutes 290.92 and 290.97? 121,Yes Do you authorize the Department to inform the prime contractor ❑ No upon it's request whether your form IC -134 has been certified? ❑ Yes If you are a subcontractor, list your prime contractor's business name and address. ❑ No Name: If you are a contractor or subcontractor, skip the next section of this form and sign below. If you are a prime contractor, fill in the names and addresses of all your subcontractors. If you need more space to list your subcontractors, attach a separate sheet. Also you must attach certified affidavits of your subcontractors and sign below. I declare under the penalti knowledge and belief. Sign Here Your signature Thal liabirty f will! ylly aking a false statement, that the above statements are true and correct to the best of my lb�iDl�6 Title D e 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, the above contractor /subcontractor has 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 of Minnesota or any of its governmental or political subdivisions. Signature of authorized Department of Revenue representative OCT 1 4 1988 Page 17 Date Name and address - A r \i t.)Y CoN3tTeocTlotJ Co. 1JrrJc. p LiTf c- CPTNAoR eb . TAW- MrJ 551 17 Name and address ,mot., %' Name and address • Name and address Name and address ' Name and address • I declare under the penalti knowledge and belief. Sign Here Your signature Thal liabirty f will! ylly aking a false statement, that the above statements are true and correct to the best of my lb�iDl�6 Title D e 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, the above contractor /subcontractor has 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 of Minnesota or any of its governmental or political subdivisions. Signature of authorized Department of Revenue representative OCT 1 4 1988 Page 17 Date