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MINNESOTA TAX CLEARANCE <br />Pursuant to Minnesota Statute 270.72 Tax Clearance: Issuance of Licenses, the <br />licensing authority is required to provided to the Minnesota Commissioners of <br />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 <br />of 1974, we are required to advise you of the following regarding the use of this <br />information: <br />This information may be used to deny the issuance, renewal or transfer of your <br />license in the event you owe the Minnesota Department of Revenue <br />delinquent taxes, penalties or interest; <br />2. Upon receiving this information, the licensing authority will supply it only to the <br />Minnesota Department of Revenue. However, under the Federal Exchange <br />of Information Agreement, the Department of Revenue may supply this <br />information to the Internal Revenue Service; <br />3. Failure to supply this information may jeopardize or delay the processing of <br />your licensing issuance of renewal application. <br />Please supply the following information and return along with your application to <br />the agency issuing the license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. <br />License Being Applied for or Renewed: Contractors License <br />Licensing Authority: City of Mounds View <br />Expires December 31, 20 11 <br />Applicant's Name (print) <br />Applicant's Address <br />Social Security Number <br />only required if no Tax ID #s) <br />Business Name <br />Business Address <br />MN Tax ID # (if applicable) <br />Federal Tax ID # <br />if applicable) <br />If MN Tax ID# not <br />Required, please explain <br />Signature of Applicant