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2016K2590185"2 DS DOR MR SEP 15 20161. MINNESOTA- REVENUE IC134 Contractor Affidavit This Contractor Affidavit must be certified by the Minnesota Department of Revenue before the state of Minnesota or any of its subdivisions can make final payment to contractors. For more detailed information,see the instructions on the back of this form. Please type or print clearly,This information will be used for returning the completed form. Company name Daytime phone Minnesot tax ID number Universal Painting and Drywall, Inc. 763-315-0095 5 39 i Address I Total contract amount Month/year work began 7308 Aspen Lane North $46,178.00 6/1/15 _.__...... ----._....._...__.....------....------.................. - ._.._._..---.... _... City State ZIP code Amount still due Month/year work ended ( Brooklyn Park MN 55428 $ 5,795.06 6/1/16 w Project number Project location 15-12 5650 Alpine Drive NW, Ramsey, MN 55303 Project owner Address City State ZIP code City of Ramsey 7550 Sunwood Drive NW Ramsey MN 55303 Did you have employees work on this project? X Yes I_._' No.If no,who did the work? .� fir; Check the box that describes your involvement in the project and fill in all information requested. k Sole contractor I^-1 Subcontractor s Name of contractor who hired you Brennan Construction of MN Inc. —.--- Address 124 East Walnut Street, Suite 20, Mankato, MN 56001 I___.J Prime contractor—if you subcontracted out any work on this project,all of your subcontractors must submit their own Contractor Affidavits and have them certified by the Department of Revenue before you can submit your Contractor Affidavit.For each subcontractor you had,fill in the information below and attach a copy of each subcontractor's certified Contractor Affidavit.If you need more space,attach a separate sheet. Business name Address Owner/Officer a 4: ----------_-----------.._.- .. __.—_ __._ _ .-_.._.. .. __...._._ ..___.._..—_...—___ .. t - t 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 information relating to this project,including sending copies of this form,to the prime contractor if I am a subcontractor,and to any subcon- tractors if I am a prime contractor,and to the contracting agency. t Contractor's signature Title Date Mail to: Minnesota Revenue, Mail Station 6610,St. Paul, MN 551.46-6610 Phone:651-282-9999 or 1-800-657-3594(TTY:Call 711 for Minnesota Relay). Certificate of Compliance Based on records of the Minnesota Department of Revenue,I certify that the contractor who has signed this Contractor Affidavit has fulfilled all the requirements of Minnesota Statutes 290.92 and 270C.66 concerning the withholding of Minnesota income tp,x from wages paid to employees relating to contract services with the startle of Minnesota and/or its subdivisions. Depar t of R venue pproval SEP Z 8 Z�16 (Rev.4/15)