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FORM SP:CJ-TAX CLEARANCE INFORMATION Pursuant to Minnesota Statute 270.72 Tax Clearance:Issuance of Licenses. The licensing authority is require to provide to the Minnesota Commissioner of Revenue your Minnesota business tax identification number and the social security number of each license applicant. Under the Minnesota Government Data Practices Act and the Federal Privacy Act of 1974,we are required to advise you of the following regarding the use of this information: 1. This information may be used to deny the issuance,renewal or transfer of your license in the event you owe the Minnesota Department of Revenue delinquent taxes,penalties,or interest: 2. Upon receiving this information, the licensing authority will supply it only to the Minnesota Department of Revenue. However,under the Federal Exchange of Information Agreement the Department of Revenue may supply this information to the Internal Revenue Services: 3. Failure to supply this information may jeopardize or delay the processing of your licensing insurance or renewal application. Please supply the following information and return along with your application to the agency issuing this license. Do not return to the Department of Revenue. LICENSE BEING APPLIED FOR OR RENEWED. LICENSING AUTHORITY: (name of City,County,or State agency issuing license) LICENSE RENEWAL DATE PERSONAL INFORMATION(if applicable} Applicant's Name: Applicant's Address: City State Zip Code Social Security Number: BUSINESS INFORMATION(If applicable} Business Name: Business Address: City State Zip Code Minnesota Tax Identification No.: Federal Tax Identification No.: If Minnesota Tax Identification number is not required,please explain on the reverse side. Signature Position(Officer,Partner,Individual,Etc.) CERTIFICATION OFCOMPLIANCE MNNESOTA WORKERS'COMPENSATION LAW L Minnesota Statute,Section 176.182 requires every State and local licensing agency to withhold the issuance or renewal of a license or permit to operate a business or engage in an activity in Minnesota until the applicant presents acceptable evidence of compliance with the Workers Compensation insurance coverage requirement of Chapter 176.The information required is:the name of the insurance company,the policy number,and dates of coverage or the permit to self-insure.This information will be