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Certificate of Compliance <br />Based on records of the Minnesota Department of Revenue, I certify that the contractor who has signed this Contractor Affidavit has <br />fulfilled all the requirements of Minnesota Statutes 290.92 and 270C.66 concerning the withholding of Minnesota income tax from wages <br />paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. <br />Department of Revenue approval Date <br />(Rev. 12/17) <br />IC134 <br />Contractor Affidavit <br />This Contractor Affidavit must be certified by the Minnesota Department of Revenue before the state of Minnesota or any of its subdi- <br />visions can make final payment to contractors. For more detailed information, see the instructions on the back of this form. <br />Company name Daytime phone Minnesota tax ID number <br />Address Total contract amount Month/year work began <br />City State ZIP code Amount still due Month/year work ended <br />Please type or print clearly. This information will be used for returning the completed form. <br />$ <br />$ <br />Project number Project location <br />Project owner Address City State ZIP code <br />Did you have employees work on this project? Yes No. If no, who did the work? <br />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 authorize the Department of Revenue to disclose pertinent <br />information relating to this project, including sending copies of this form, to the prime contractor if I am a subcontractor, and to any subcontractors if I am a prime contractor, and <br />to the contracting agency. <br />Contractor’s signature Title Date <br />Mail to: Minnesota Revenue, Mail Station 6610, St. Paul, MN 55146-6610 <br />Phone: 651-282-9999 or 1-800-657-3594 <br />Check the box that describes your involvement in the project and fill in all information requested. <br />Sole contractor <br />Subcontractor <br />Name of contractor who hired you <br />Address <br />Prime contractor—If you subcontracted out any work on this project, all of your subcontractors must submit their own Contractor Affidavits <br />and have them certified by the Department of Revenue before you can submit your Contractor Affidavit. For each subcontractor you had, fill <br />in the information below and attach a copy of each subcontractor’s certified Contractor Affidavit. If you need more space, attach a separate <br />sheet. <br />Business name Address Owner/Officer