Exemption From Surety Deposits For Non-Minnesota Contractors Form - Minnesota Department Of Revenue
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Exemption from Surety Deposits for Non-Minnesota Contractors
Please type or print clearly. This will be your mailing label for returning the form to you.
Contractor
Total contract amount
Minnesota tax ID number
$
Address
Contact person
Daytime phone
(
)
City
State
Zip Code
Contract starting date
Projected completion date
Business type (check one):
Corporation
S corporation
Partnership
Sole proprietor
Name of business or government agency
Contact person
Daytime phone
(
)
Contract owner’s address
City
State
Zip Code
Project number
Project location address
City
State
Zip code
I request exemption from surety deposits under Minnesota law (MS 290.9705) for the following reason
(check one and complete the information requested):
I have a cash surety or a bond secured by an insurance company licensed in Minnesota. The bond must be 8 percent of
the total contract amount. Attach a copy of the bonding agreement.
Bonding company
Bonding agent
Address
Daytime phone
(
)
City
State
Zip code
Period of bond (month/day/year)
From
/
/
To
/
/
I have done construction work in Minnesota during the past three calendar years and have fully complied with Minnesota
law regarding Minnesota income, sales and withholding taxes.
I am performing work for a government agency and have a payment and performance bond.
I am performing work for a government agency and have a cash surety issued by a state bank, national bank, or savings
and loan association doing business in Minnesota.
I declare this information is true and complete to the best of my knowledge and belief. I authorize the Department of Revenue
to send a copy of this form to the contract owner and discuss this case and related taxes with the bonding company.
Contractor’s signature
Title
Date
Mail to: Minnesota Revenue, Mail Station 6501, St. Paul, MN 55146-6501
Department of Revenue Approval
The above-named out-of-state contractor is exempt from the surety requirements of Minnesota Statute 290.9705 for this
project.
Department of Revenue approval
Date
Stock No. 5002070 (Rev. 8/08)
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