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CITY OF MOUNDS VIEW-TAX CLEARANCE <br /> Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the licensing authoring is required to <br /> provide <br /> to the Minnesota Commissioners of Revenue your Minnesota Business Tax Identification Number and the social security <br /> number of each license;applicant. <br /> Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you <br /> of the following regarding the use of this information: <br /> 1. This information may be used to deny the issuance, renewal or transfer of your license in the event you owe the <br /> Minnesota Department of Revenue delinquent taxes, penalties or interest; <br /> 2. Upon receiving this information, the licensing authority will supply the information only to the Minnesota Department <br /> of Revenue. However, under the Federal Exchange of information Agreement, the Department of Revenue may <br /> supply this information to the Internal Revenue Service; <br /> 3. Failure to supply this information may jeopardize or delay the processing of your licensing application. <br /> Please supply the following information and return along with your application to the agency issuing the license. DO NOT <br /> RETURN TO THE DEPARTMENT OF REVENUE. <br /> License A lied fvrlienewed: <br /> Licensin Authorit : CITY OF MOUNDS VIEW <br /> License Renewal Date: <br /> A licant Name: -4 u A,%) <br /> A licant Address: yr Z <br /> A licant SS#: in � <br /> Business Name: —>ft,J1L `l a <br /> Business Address: <br /> MN Tax ID#: rt <br /> Federal Tax ID 4: <br /> If Minnesota Tax ID is not <br /> required. pleasr,ex lain: <br /> CERTIFICATION OF COMPLIANCE WITH THE •MINNESOTA WORKERS' COMPENSATION LAW <br /> Minnesota Statute, Section 17E,182 requires every state and local licensing agency to withhold the issuance or renewal of <br /> a license or permit to operate a business or engage in any activity in Minnesota until the applicant presents acceptable <br /> evidence of compliance with the Workers' Compensation insurance Coverage Requirement of Chapter 176. The <br /> information required includes: the name of the insurance company, the policy number, and dates of coverage or the ,permit <br /> to self-insure. This information will be collected by the licensing agent and retained in their files. <br /> This information is required by law and a license or permit to operate a business may not be issued or renewed if information <br /> is not provided and/or is falsely reported. Further, if this information is not provided or is falsely stated, it may result in a <br /> $2,000 penalty assessed against the applicant by the Commissioner of the Department of Labor and Industry. <br /> PC <br /> N! ent : R,d, <br /> „ <br /> C <br /> (OR) <br /> I am not required to have workers'compensation liability coverage because: <br /> I have no employees <br /> I am self-insured (include permit to self-insure) <br /> I have no employees who are covered by the workers' compensation law(these include: Spouses, Parents, <br /> Children and certain farm employees) <br /> I certify that the information provided above is accurate and complete and a valid workers'compensation policy will be <br /> kept in effect at all times as required by la <br /> k 5i natureclAnIDlicanr7 <br /> Com an Narne: A vjIu 's� A.4kll r <br /> Date: I Q J ►'fit <br />