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Form IC-134 Flev. 11/90 Minnesota Department of Revenue Withholding Affidavit for Contractors This affidavit must be approved by the Minnesota Departn State of Minnesota or any of Its subdivisions can make fir Company name Bi Luminous Consulting & Minnesota le number Contracting Co., Inc. Address 2456 Main Street NE Mpls, Mn 55449 City Slate Zip Code Please type or print clearly above. This will be your mailing label for returning the completed form. I of Revenue before the tayment to contractors. 6636955 Month/year work began 10/93 Mon(tr/year work ended 6/94 Total contract amount: $182,662.50 Tale hone number Amount still due: 1612) 755-1888 $16,940.00 Did you have employees work on this project? Projectnumber: 1993 Bituminous Patch & Ove If none, explain who did the work: Project localion:, various Streets —Lake Elmo P-mi towner: City of Lake Elmo _ YES Address 3800 Laverne Ave. No. Lake Elmo MN 55042 Check the box that describes your Involvement in the project and fill tit all information requested in that category: ® Sole contractor ❑ Subcontractor If you are a subcontractor, fill in the name and address of the contractor that hired you: ❑ Prime Contractor If you subcontracted out any work on this project, all of your subcontracicrs must file their own IC-134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each subcontractor you had, fill in the business information below, and attach a copy of each subcontractor's certified IC-134. (If you need more space, attach a separate sheet.) Business name Address Owner/Officer I declare that all information I have filled In on this form is true and complete to the best of my knowledge and belief. I authorise he Depa Revenue to disclose pertinent Information relating to this project, including sending copies of this form, lo_ e_prim contractor it m a subcontractor, and to any subcontractors_ if I am a prime contractor, and to the contracting agency.. _ -_-..- __- -......_ _. Contractor's n. a Title Date X_,L Yr e_ _ Controller 10/11/94 For certification, mail original and one copy to: Minnesota Department of Revenue, Business Trust Tax Section Mail Station 6610, St. Paul, MN 55146-6610 Certificate of Compliance with Minnesota Income Tax Withholding Law Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this certificate has { 'fulfilled all the requirements of Minnesota Statutes 290.92 and 290.97 concerning the withholding of Minnesota income tax from wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. Date OCT 14 1994 lay Stock No. 5000134