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the licensing authority is remulreO to provloe to the Minnesota <br />Commissioner of Revenue your Minnesota <br />anU the social security number of each license applicant. <br />UnOer the Hlnnesota Government D~ta practices Act eno the Federal Privacy <br />Act of J974o we ere remuirea to aOvlsm you of the following regaralng the <br /> I. lhls in6orn~tlon mey be used to Oeny the issuance, renewal or <br /> transfer of your license )n the event you owe the ~)nnesota <br /> Department of Revenue oelinnuent taxes, penalties or Interest; <br /> Upon receiving this In6orm~tlon, the licensing authority will <br /> suPPly It only to the Hjnnesota. Demartment of Revenue. However, <br /> unOer the FeOer~l Exchange of information Agreement the <br /> <br /> · Demartment of Revenue m~y supply this information to the Internal <br /> RevenUe Service; <br /> Failure to suomly this information may ~eo~arOIze or ~el~y the <br /> mrocessin~ of your licensing Insuance or renewal <br /> Please su~mly the Follmwin~ information an~ return elon~ with your <br /> aoollc~tion to the ~gency t~suing the license. PO hK)T RETURN TO THE <br /> DEPART~E~T~ REVENUE. <br /> <br /> LICENSING AUTHOR]TY: . <br /> (name of city, coun:y or s:a:e agency ~ssu'n' l~cense) <br /> L]CENSE RENEWAL DATEs - <br /> <br />BUSINESS INFO,RMATION <br /> <br />Zi~ Co=e <br /> <br />~innesc~ Tax ]~en~Ific~tton NO.: <br /> <br />Cooe <br /> <br /> - .,,:-~ please ex~lein <br />if e ~innesota Tax ] ......... - '~' <br /> <br />S i _cn=ture <br /> <br />F~csi-clon (OFficer. Far:ner. _so ) <br /> <br /> <br />