HomeMy WebLinkAboutMN Tax ID-Workmans Comp Certification»MINNESOTA BUSINESS TAX IDENTIFICATION LAW
If property owner is sole proprietor, supply that individual's information here. If the property is owned by a business, supply the
business' information here.
Pursuant to Minnesota Statute 270C.72 (Tax Clearance; issuance of licenses), Subd. 4. All licensing authorities must require the
applicant to provide the applicant’s Social Security number OR individual taxpayer identification number AND Minnesota Business
Identification number on all license applications. 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.
PROPERTY OWNER (LAST, First, Middle Initial)SOCIAL SECURITY NUMBER FEDERAL TAX IDENTIFICATION NUMBER MINNESOTA TAX IDENTIFICATION NUMBER
HOME ADDRESS CITY STATE ZIP CODE PHONE NUMBER
BUSINESS NAME (If applicable)TYPE OF LICENSE APPLIED FOR
Rental Occupancy License
BUSINESS ADDRESS CITY STATE ZIP CODE PHONE NUMBER
IF A MINNESOTA TAX ID NUMBER IS NOT REQUIRED, PLEASE EXPLAIN:
» CERTIFICATE OF COMPLIANCE - WORKERS’ COMPENSATION INSURANCE COVERAGE LAW
Minnesota Statutes, 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 in Minnesota until the applicant presents acceptable evidence of compliance with the workers'
compensation insurance coverage requirement of Minnesota Statutes, Chapter 176.181, Subd. 2. 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
collected by the licensing agency and put in its company file. It will be furnished, upon request, to the Department of Labor and
Industry to check for compliance with Minnesota Statute Section 176.181, Subd. 2.
This information is required by law, and licenses and permits to operate a business may not be issued or renewed if it is not provided
and/or is falsely reported. Furthermore, if this information is not provided and/or is falsely reported, it may result in a $2,000 penalty
assessed against the applicant by the Commissioner of the Department of Labor and Industry payable to the Special Compensation
Fund.
WORKER’S COMPENSATION INSURANCE COMPANY NAME (Not agent’s name)POLICY NUMBER DATES OF COVERAGE
FROM TO
OR, I certify that I am not required to carry worker’s compensation insurance because
(check one)
⃝ I am the sole proprietor and have no employees
⃝ I am self-insured (For this category, you must include a copy of the permit to self-insure.)
⃝ I have no employees who are covered by worker’s compensation law. (Only employees who are specifically exempted by statute
are not covered by the worker’s compensation law. These include; spouse, parents, children – regardless of age, and farm labor
employees of a family farm that spent less than $8,000 for farm labor in the previous calendar year. All other workers whose work
is controlled by the employer must be covered.
»I certify that all information provided above is accurate and complete. I also certify that a valid workers' compensation policy will
be kept in affect at all times, as required by law.
SIGNATURE PRINT NAME DATE
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