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r <br />mI #• <br />INESOTA Department of Revenue <br />WiffhholdiflTig Affidovifi ’ fee* €@ri)ftr6idi^irs <br />. ’T^S^ This affidavit must be a^roved by the Minnesota Department of Revenue before the slate of <br />> Minnwoto or ony of its suMivislons can make final payment to c jntractors. <br />1 <br />t <br />i <br />^Com^onf nom§ <br />I Addrtfi <br />i A/ ’ni.nci /^y <br />|Ci»K Ztp Cod* <br />Pireioel ntimbtr <br />Protoet o«rn*f <br />P/0|*cl locotion <br />n ^ <br />I yov w* <br />‘irk <br />Old yov wodi on Hvt pro|ocff <br />I ^f!l ^iaK.c ii,. <br />^ Doytim* ption* <br />1 OS'! <br />Minnosoio fox lO nuinb*f <br />i»6o3srr <br />1 Total conkocl onouM Monfh/yoor wort bogon <br />1 $ j?o-7, n 3/mn/ os <br />1 AmownI stiM d^* <br />; $ /o.^/'rL ..^ S <br />Monfh/yoor work ondod <br />/r>/c.rr <br />' C.ly Sioi« Zip cod* <br />f -T ir <br />m <br />, who did ih« work? <br />Ciwck rfi# box that doscribos your invotvonwnf tr) the pro/ect and fill in all informotion requested. <br />rZkfoio contractor <br />I I Suhcontfoctor_________________________________________________ <br />I- .. .Mom* of conkoclof who hirod yoo <br />Addr«s» <br />□ Priflio contractor—If voo jobconirocicd out ony work on this project, oil of your subcontroctors most file their own <br />ICI34 olhdovils ond hove them certified by the Deportment of Revenue before you con file your offidovit. For eoch <br />sobcofttfoctof you hod. fi'l in the informot.on below ond oHoch o copy of eoch sobcontrcci ir's certified IC I34. If you <br />need more spcce, ottoch c seporote sheet. <br />Adty*fi__________ Owr.«r/Otfi<tBtntn*» nomt <br />t dedoro ihoi ett mtofmohc ^ t ho^ tittod >n on thn form <s rru* ond cofopioto <o iht oou oi my Lno^hego ond holtd. I oitrcnzo •hg Ogc<ufninf oi <br />PoYonug to d'lc/oi* pofttnom information rgloHng Hs *his proi§a, tndjdmg ionrung ccpiws oi Inn torm to tng pr.mg controitot u i cm o iubcorj.cc.\x. <br />end to ony wbcontroaofs if I om a pnmg controiiti* nnd ro lontrocting oggnry <br />-----------------------------------------------------------------------^ — <br />ControclOf'l it^noiwt* <br />I I.**-' • <br />' ' - p /t y ' . <br />r"’ i <br /><• <br />*r> >C - ^ <br />i.kiJj tv.t !vM-.fD#pi c! n«v«nue. Wiihholdmg Divisicn, f/ioil Sloiicr. 66i0. Ci fcul, MM !0 <br />«o««d OP -ecr-rds c? ihe ••^innei*'- D«ir'*'^SP' o' f-r en.-e > -•»ri f' 'hci ihv c-J.vrc't.or wU Kci szr^-i iPn rwrivcn n?j <br />fuliiiiid cH m* rrouiremenij ol minr^eiOic S'otults 2W.92 ord 29C97 corcefninp il-.* -i.hholdincj d .'A.nne.c o •nco^Ts <br />from vooes ccid to •mplo'.'res '•istinc io cc>n'":tt ifvce! vith ih» sm s d pninnsto^o ond/cr it> <br />0gpor*f^9^ d itg*-§nuf opofO^\'X* - <br />H*