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' . ^ 15 1816 <br /> MP1ffSh01HTA~ R.EVENKlE <br /> Contractor Affidavit <br /> ����u.m���n��~�� <br /> This Contractor Affidavit must be certified by the Minnesota Department of Revenue before the state of Minnesota or any of its <br /> subdivisions can make final payment to contractors. For more detailed information,see the instructions on the back of this form. <br /> Please type mprint clearly.This information will beused for returning the completed form. <br /> ___ _ _ _ _ _ _ _ _ _ _- <br /> ������ <br /> ( \ Daytime phone <br /> Brennan Construction ufWYN' �|no ' 3023981 <br /> � | 507-625-541' <br /> | <br /> Total contract <br /> Month/year work began <br /> 124 East VVa|nutStreet, Suite 20 | amount-- - — <br /> Amount� 3,220,692 03/2015 <br /> | ' <br /> ( Mankato yWN 56081 | $ 80,517.00 08/2016 <br /> __ _ _ ___ _ _ _ _ _ _ _ _ _ _ _ <br /> Rroject number <br /> Project location <br /> 15-12 5650 Alpine Drive NW, Ramsey, MN 55303 <br /> 0 ner Address city State ZIP code <br /> City of Ramsey 7550 Sunwood Drive NW Ramsey MN 55303 <br /> Did you have employees work on this project? xs No.nno,who did the work? <br /> Check the box that describes your involvement mthe» eotand fill inall information requested. <br /> Sole contractor <br /> u <br /> Subcontractor <br /> Name of contractor who hired you <br /> Address <br /> =� pnmncnntraomr-nyouuobcom:axtednutpnywnrkonthispx800t,a||vfyou/suboontmmoxsmustauhmkthoirmwnContmux, <br /> Affidavits and have them certified Uvthe Department ofRevenue before you can submit your Contractor Affivavit.For each <br /> subcontractor you had,fill|nthe information below and attach acopy ofeach subcontractor's certified Contractor AffiUavit.|fyou <br /> need more space,attach aseparate snoot� <br /> Business name <br /> Address <br /> See Attached List <br /> ' ___ .......... _ <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 Departmentmn^venvom <br /> disclose pertinent information relating mthis project,including sending copies orthis form,mthe prime contractor n/omasubcontractor,and many svuoon' <br /> v�owmx/amavmnvmnvnvm«anuwmoo"ouaxmmm*nc� <br /> R signature <br /> Contrz 1or' Title Date <br /> Controller 9/8/16 <br /> Mail to: Minnesota Revenue, Mail Station St. Paul, MN 55146-6610 <br /> Phone:851-282'S0gAo/1'80O-657-35A4(TTYCall 711for Minnesota Re|ay). <br /> Certificate of Compliance <br /> Based on records of the Minnesota Department of Revenue,I certify that the contractor who has signed this Contractor Affidavit <br /> has fulyl!pj all the requirements of Minnesota Statutes 290.92 and 270C.66 concerning the withholding of Minnesota income <br /> tax frW, wag�ypqjcl y5 employees relating to t t . s with the state of Minnesota and/or its subdivisions. <br /> .4n r9c service <br /> of f? IIAP4 <br /> Lie <br /> Department ev6n 1..")J Date <br /> ocr .1 0 <br /> � <br />