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Docusign Envelope ID: 5D66C3E7-F3E1-44CE-81D8-6D9698D8B023 <br />Contract# C0011019 <br />ANOKA COUNTY HUMAN SERVICES <br />CONTRACTOR INFORMATION SHEET <br />Please review the following information for accuracy and Angie Rodine <br />completeness, indicate any changes, sign and return to: Anoka County Human Services <br />2100 3'd Ave, Suite 500 <br />Anoka, MN 55303 <br />LEGAL NAME FOR CONTRACTOR: Lino Lakes, City of <br />(Legal name and name on Certificate of Insurance must be exactly the same in order for County Signatures to be obtained on the <br />Contract.) <br />Doing Business As: <br />Business/Corporate Address: <br />Lino Lakes, City of <br />600 Town Center Pkwy <br />Lino Lakes, MN 55014 <br />National Provider Identification (NPI) #: <br />Federal Tax Identification #: 41-0883446 <br />NOTICE: Federal Business Tax ID/Social Security Number is needed for tax purposes as mandated by Section 1211 of the Tax Reform Act <br />of 1976 and Minn. Stat 270.66. This information will be shared with the Minnesota Department of Revenue, the Minnesota Department <br />of Human Services, the Internal Revenue Service, and the U.S. Department of Health, Education and Welfare for the purposes of <br />administering the income tax, child support obligation and social security tax programs. <br />Individual who Contractor is designating to receive notice under the contract and to act as the responsible <br />authority for data requests under the Minnesota government data practices act (Minn. Stat. Chap. 13): <br />Name: Phone: Fax: Email: <br />Andrew Nelson 651-982-2465 651-982-2499 anelson3@ci.linolakes.us <br />Signature (Required): <br />Insurance Agency: <br />Telephone Number of Insurance Agent: <br />Person Completing this Form: <br />Name <br />Date: <br />Name of Agent: <br />Title: <br />Phone: Fax: Email: <br />