Agenda - Council - 11/22/2016 - Laserfiche WebLink

Home

RECEIVED MINNESOTA- REVENUE AUG 1 5 2016 IC134 Withholding Affidavit for Contractors Per Thisaffidavit must be approved 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. I his information will be used for returning the completed form. company name Daytime phone Minnesota tax ID number C 12- 60f-1 '52�4 L11 IS ................................ f�li'- W ........... ....................---..................... -4 Address I contract amount Month/year work began Oily State ZIP carie Amount still doe Montli/year work ended $ t ofL ... ......... Project number Project location r- D 1 1 ........... Project owner Address city state ZIP code —2 -755c> Did you have employees work on this project? -Yes No.If no,who did the work? Yes ........................................ ....................... .......................—--------- Check the box that describes your involvernent in the project and fill in all information requested. IL-J Sole contractor Subcontractor .................. Name of contractor who hired you Address IJ M) .......... ..................... .............----------- ......... (D Prime contractor—if you subcontracted out any work on this project,all of your Subcontractors must file their own contractor al- fidavits(IC134)and have them certified by the Department of Revenue before you can file your affidavit For each Subcontractor you had,fill in the information below and attach a copy of each Subcontractor's certified IC134.If You need more space,attach a separate sheet. .................................................................................................................... .......... ---------..................... Business name Address Owner/officer ........... ............................ .......................................... ....... ........................................- ------------ ............ ............ .......... ....................... ...................-..................................... ............ ............... ......................... I declare that all information I have filled in on this form is true and complete to the best of my knowledge and bi-Jief.I authorize the Department of Revenue to disclose pertinent inforniation relating to this project,including sendfng copies of this form,to the prime contractor if 1,111)a Subcontractor,and to any subcon- tractors if I am a prime contractor,and to the contracting agency. ... ............... ........... ...................... ------------ .................................................. Go lit ra Title Date 1 r—Le 4"d Mail to:Minnesota Revenue, Mail Station 661.0,St.Paul,MN 55146-661-0 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 certificate has ful- filled all the requirements of Minnesota Statutes 290.92 and 270C.66 concerning the withholding of Minnesota income tax from wag ,a contract services with the state of Minnesota and/or its Subdivisions. I)ep , catK SEP Date 282016 (Rev.1,1/13)