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Form IC-134 Rev 9 89 Minnesota Department of Revenue ^ Withholding Affidavit for Contractors This affidavit 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.A\3V-J1 Company twno Minnasota 10 number Keys Well Drilling Company 8105506 N. Lexington Pkwy. Monttvyaar work began I'lovember , 1989 OtvSt. Paul Stata Mil Zip Coda 5510^+Montfi/yaar work ended April, 1990 Total contract amount: $36,532.50 Tataphona numbar Amount still due ( 612) 6U6-T8T1 $uTT6.38 Did you have employees work on this project?Project number; l^oUS if none, explain who did the work:Project location: Qrono , Minnesota vrc Project owner: Citv of Crono Address Box 66, Cystral Bay, Mil 55323 Check the box that describes your involvement in the p'oject and fill in all Information requested in that category: £ Sole contractor G Subcontractor If you are a subcontractor, fill in the name and address of the contractor that hired you; Prime Contractor If you subcontracted out any work on this project, all of your subcontractors must file their own IC-134 affidavits and have them certified by the Department of Revenue before you can file your affidavit. For each subcontractor you had. fill m the business information below, and attach a copy of each subcontractor s certified IC-134. (If you need more space, attach a separate sheet.) Business name Address Owner Offic -r ___ i (JttCraie trial an iiiioimation i fiave imed .n on inii tomi .s irue ano complete lo ina pesii o( my «noi^i«age and Ueiiel I aotnon;® the Department ol Revenue lo disriose pertinent 'nlotmation relating to inis proiect including sending copies ol this form, to the prime contractor if I am a subcontractor, ano to any suDcontractors iM am a prime contractor and to the contracting agency T.iw' Oat*Contractor * figrtatur* 1 yf/. . / Jeffrey W. Keys Secretar;.' Treasurer T-12-90 __ For certification, mail to: Minnesota Department of Revenue. Business Trust Tax Section Mail Station 6610. St. Paul. MN 5514t'-66l0 Certificate of Compliance with Minnesota Income Tax Withholding Law Based on records of the Minnesota Department of Revenue. I certify that the contractor who has signed this certificate has fulfilled all the requirements of Minnesota Statutes 290 92 and 290 97 concerni.nii the withholding of Minnesota income tax from wages paid to employees relating to contract services with the state of Mmnesotu and or its subdivisions JUL 1 3 1990