Agenda - Council - 07/09/1996 - Laserfiche WebLink

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Form IC-134 Rev. 11/90 Company name Minnesota Department of Revenue Withholding Affidavit for Contractors 'I his affidavil must be approved by the Minnesota Department of Revenue before the State of Minnesota or an~ of its subdivisions can make final~._ayment to contractors. Minnesota ID number Bonine Excavating, Inc. Address ]2669 Meadowvale Road Oily Elk River s~at~N z~pc~a 55330 6901604 Monlh/year work began 8/95 Please type or print clearly above. This will be your Toll conlract amount: mailing label for returning the completed form. $ 103,580.00 Telephone number Amount still due'. ( 6]2 ) 44]-8]04 $ 1959.02 Did you have employees work on this project? yes If none, explain who did the " wor~, Project number: 95- 18 I Projectloca[ion: River/47 Plaza Project owner: C~ty of Ramsey Addros[~ Rams ey, MN Check tho box that describes your involvement in the project and fill in all information requested in that category: [] Sole contractor [2 SubLuntruclof II you utu a subcontractor, fill In lhu name und addreus ol thu co~tractor thai Iflrud you: [] Prime Contractor If you subcontracted out any work on this project, all of your subcontractors 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 ol each subcontractor's certified IO-134. (If you need more space, attach a segarate sheet.) Business name Address Owner/Officer I I I I I I I I I' t I declare that all information I have tilled in on this form is true and complete to the best of my knowledge and belief. I authorize .~_._' ~he Department of Revenue to disclose per(inent information relating fo fhis project, including sending copies of fhis form, to 1he.me comr/,acto~f I am a subcontraclor, and to an), subcontractors if I am a prime contractor, and to the contracting agency. ~'~r'~-or's .~,,T~.'iaiU.'~ ~'j / / * Tille ' ' Dale - "~' l~'~--'~';~' ~////~')~) ¢//"~/'/~'Forcertlf,catlorl,f~ilveO~ii:nra~i~n,eT?upy to Se tn "ay '5, ]996 ' eot 'ep rt t e, ' ess st Tax ct'o Mmn s aD a men o Mail Station 6610, St. Paul, MN 55146-6610 Certificate of Compliance with Minnesota Income Tax Withholding Law Based on records of the Minnesota Department ot Revenue, I certify that the contractor who has signed this cedificate has fulfilled all the requirements of Minnesota Statutes 290,92 and 290.97 concerning the withholding of Minnesota income tax fro; wages paid to employees relating to contract services with the state of Minnesota and/or its subdivisions. SIock No, 500H134 II