TAX IDENTIFICATION FORM
LICENSE APPLICANT:
Pursuant to *Minnesota Statute 270C.72 Tax Clearance: Issuance of Licenses, the licensing authority is required
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 Service:
3. Failure to supply this information may jeopardize or delay the processing of your licensing issuance or
renewal application.
Please supply the following information and return along with your application to the agency issuing the license.
DO NOT RETURN TO THE DEPARTMENT OF REVENUE.
Name of Applicant _____________________________________________________________________________
Social Security #*_______________________________________________________________________________
For individual business owner only, not partnership, corporation, etc.
Type of Business _______________________________________________________________________________
Minnesota Tax Identification # ____________________________________________________________________
Federal Tax Identification # ______________________________________________________________________
Signed by _________________________________________________ Date ____________________________
Print Name of Person Signing: __________________________________________________________________
If a Minnesota Tax Identification Number is not required, please explain below.
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
*2008 Minnesota Statutes
270C.72 TAX CLEARANCE; ISSUANCE OF LICENSES.
Subd. 4.Licensing authority; duties.
All licensing authorities must require the applicant to provide the applicant's Social Security number and
Minnesota business identification number on all license applications. Upon request of the commissioner, the
licensing authority must provide the commissioner with a list of all applicants, including the name, address,
business name and address, Social Security number, and business identification number of each applicant. The
commissioner may request from a licensing authority a list of the applicants no more than once each calendar
year.
History:
2005 c 151 art 1 s 87
TO BE SUBMITTED WITH APPLICATION
TO BE SUBMITTED WITH APPLICATION
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