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,'. ;, , . <br /> REEIVED <br /> MIhTNESOTAii REVENUE I 4 <br /> Withholding Affidavit for Contractors N"R <br /> cJti <br /> This affidavit must be approved by the Minnesota Department of Revenue before the state.of Minnesota or any of itsj Tvisions <br /> can make final payment to contractors.For more detailed information,see the instructions on the back of this form. <br /> Please type or print clearly.This:Information will be used,for returning the completed form. <br /> I i:Tompariylnamo ~—— — — ——— —..� Daytime phone 'Minnesota tax ID number <br /> Best Built Fence Co _ : 715 426 0457 9125690 <br /> ( <br /> -----Address^ :� total contract amount Month/yearwodc been <br /> 403 State Road $5689,20 06/2015 <br /> — =-------—----- <br /> Ddy '.State ZIP cede I Amount still due Month/year work ended: <br /> River Falls WI 54022 ) $284.65 1/25/16 <br /> Project number ProJeot location <br /> e 15-12 Ramsey N <br /> tett^ Project owner Address Citystate `7JP code <br /> q City Of Rasmey - — Rasmey Mn <br /> - Did you have employees work on this project? a Yes No,if no,who did the work? <br /> Check the box that describes your Involvement in the project and fill In all information requested. <br /> Sole contractor <br /> 0 Subcontractor <br /> Name of contractor who hired you <br /> Brennan Companies <br /> Address <br /> 124,East Walnut Street Suite 20_Mankato,MN — <br /> �, 'El Prime contractor-If you subcontracted out any work on this project,all of your subcontractors must file their own contractor at- LU <br /> fidevits(IC1B4)and have them certified by the Department of Revenue before you can file your affidavit;For each subcontractor I" <br /> you had,fill In the Information below and attach a copy of each subcontractor's certified IC134.If you need more space,attach a <br /> separate sheet. <br /> Business name Address Owner/officer <br /> i. <br /> 1 declare that all information l have tilted In on this Form is true and complete to the best army knowledge and belief.l authorize the Department of Revenue to <br /> disclose pertinent InformationI facing to this project Including sending copies of this form,to the prime'contractor it am a subcontractor,and to any subcar <br /> 'tractors if I am a prime contra ,a d to the contracting agency. <br /> :Contractor's-,� re : Title --- --- ---Date <br /> w President/owner 4/28116 <br /> Mall to;Minnesota Revenue,Mail Station 6610,St.Paul,,MN 55146-6610 <br /> Phone:65,3-282-9999 or 1800-657-3594(TTY:;Call 711 for Minnesota Relay), <br /> Certificate of Compliance <br /> Based on records of the MinnesotaDepartment of Revenue,I certifythat the contractor who has signed this certificate has fui- <br /> filled ail the requirements of Minnesota Statutes 290.92and 270066 concerningthe withholding ofMinnesota income tax from- <br /> wages paid toe ployBes relatingto contract services with the state of Minnesota and/omits subdivisions. <br /> Department ofR tie appro t Date <br /> tRev.suia, �y <br /> t <br />