Agenda - Council - 07/13/2004 - Laserfiche WebLink

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Form SP:CI LICENSE APPLICANT: Pursuant to Minnesota Statute 270.72 Tax Clearance; Issuance of Licenses, the licensing authority is required to provide to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the Social Security Number of' each license applicant. Under the Mhmcsota Government Data Practices Act and the Federal Privacy Act of 1974, we are required to advise you of the fbllowing regarding the use of tiffs in_formation: l. This information may be used to deny the issuance, renewal, or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes, penalties, or interest, 2. Upon receiving this infm-mation, the licensing authority will snpply it only to the Minnesota Department of Revenue. However, under the Federal Exchange of Information Agreement the-Deparm'~ent of Revenue may supply this infbrmation to the Internal Revenue Sex-vice. 3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or renewal application. Please supply the following inlbrmation and return along with your application to the agency issuing the license. DO NOT RETURN TO THE DEPARTMENT OF REVENUE. License Being applied for or renewed: Licensing Authority: (Name of City, County, or State Agency issuing License) Pawb. broker City of Ramsey License Renewal Date: PERSONAL IN'FORMATION (ii' applicable): Applicant's Name: Applicant's Address: 5tate' Social Security Number: BUSINESS INFORMATION (it' applicable): Business Name: - Federal Tax Identification No.: Ifa Minnesota Tax Identification number is not requked, please explain on the reverse side. Signature Position (Ofricer, Partner, etc.) Date