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Personal Information
License Number
License Level
License Level
AMA
SAMA
None
First Name
Middle Name
Last Name
Have you used other names in the past 4 years?
Yes/No
Yes
No
Previous names
Home Address
Unit or PO Box Number
City
State
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code
County
Phone Number
Email
Your home address, whether you have filed all of your required Minnesota Income Tax Returns and whether you owe taxes to the State of Minnesota are private information and cannot be disclosed to others without your request. The Department of Revenue can use this information for tax administration purposes. All other information on the form, including your work address, is public.
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