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5.c. Consideration of a Business Relocation Claim from Tourdot Upholstery, Inc.
BUSINESS RELOCATION CLAIM FEBRUARY, 1993 TOURDOT CUSTOM UPHOLSTERY, INC. 13985 SOUTH ROBERT TRAIL ROSEMOUNT, MN PARCEL #34-02010-031-60 ROSEMOUNT PORT AUTHORITY ARMORY SITE PROJECT CONWORTH, INC. e CONWORTH, INC. 4725 Excelsior Blvd. Suite 200 Minneapolis, MN 55416 (612) 929-0044 February 22, 1993 John R. Miller Economic Development Coordinator Rosemount Port Authority 2875 145th Street West P.O. Box 570 Rosemount, MN 55068-5010 Subject: Payment in Lieu of Actual Moving Expenses for Tourdot Custom Upholstery, Inc. 13,985 South Robert Trail #34-02010-031-60 Rosemount Port Authority Armory Site Project Dear Mr. Miller: Enclosed please find two executed copies of the Business Relocation Claim for the above -referenced concern. We have reviewed the claim documentation submitted by the business and have assembled the enclosed claim booklets. We believe all is is accordance with applicable relocation regulations, and request your review of the enclosed information. Upon your approval of this relocation claim, please make payment to Tourdot Custom Upholstery in the desired amount as 'shown on the Summary Page at Exhibit 1 of the enclosed booklets. Thank you for your consideration of this request. We submitting this claim at this time to enable the business to finance their move. No subsequent claims are anticipated. If you should have any questions, please do not hesitate to call. Sincerely, Jacquelyne Wentworth Owner/Consultant sl Enclosures Redevelopment Acquisition/Relocation EXHIBITS 1} SUMMARY 2) MnDOT RELOCATION CLAIM FORM - FIXED PAYMENT IN LIEU OF ACTUAL MOVING AND RELATED EXPENSES 3) NARRATIVE REGARDING ELIGIBILITY FOR FIXED PAYMENT, AND INDIVIDUALIZED COMMENTS 4) NARRATIVE REGARDING AMOUNT OF FIXED PAYMENT, INDIVIDUALIZED COMMENTS, AND DOCUMENTATION 5) CLAIMANT'S CERTIFICATION REGARDING BUSINESS AND FINANCIAL STATEMENTS 6) NOTICE OF RELOCATION ELIGIBILITY 7) 90 -DAY VACATE NOTICE 8) RELEASE OF PROPERTY :8) RECEIPT FOR RELOCATION INFORMATIONAL BOOKLET 10) CERTIFICATION OF CLAIM 11) QUALIFICATIONS OF CONSULTANT CONWORTH INC. SUMMARY Occupant Name: Tourdot Custom Upholstery Inc. Date and Type of Initial Occupancy: 1972 as owner Business Owner: Earl Tourdot Date Claimant Notified Consultant of Move: February 18, 1993 Business Description: This corporation specializes in custom upholstery. Type of Payment: Fixed Payment in Lieu of Actual Moving -Related Expenses Amount of This Claim: $15,992.65 Amount of Previous Claims: -0- Total Claims to Dater $15,992.65 Less Amounts Paid in Advance: -0- Total Dues $15,992.65 Send Payment To: Earl J. Tourdot - -Tourdot Custom Upholstery, Inc. 13985 S. Robert Trail Rosemount, MN 55068 CONWORTH, INC. MHD 25334 (1-74) STATE OF MINNESOTA DEPARTMENT OF HIGHWAYS COMPUTATION FOR AVERAGE ANNUAL NET EARNINGS Name Tourdot Custom Upholstery, Inc. S.P.Parcel #34-02010-031-60 Fed. No. County Dakota jiEarl J. Tourdot Par. No. Owner Trail 13985 S. Robert Rosemount Address City Type of Acquisition N/A FOR STATE USE ONLY Approved Amount E 15,992.65 Approved Acq. Engr. or R/W Approved Relo. Mgr. Date Application Approved Mail Check To: Net Earnings for 15 , 866.15 Net Earnings for the Yearr 1992 S 16,11&18 3$ Average Annual Net Earnings S 15,992.65 Maximum payment may not exceed MUM $20,000.00' TRAN VENDOR NUMBER YPE INVOICE NUMBER ORGANIZATION SEQ. NO. SUFF 'EPT.PO/FO NO OBJECT AMOUNT OF INVOICE DATE SUB ACT TASK: UB TASK COST/CLIENT CODE FED REV I hereby certify that the goods or materials covered by thisclaim have been inspected and received or the services have been perfor. med, and are in accordance with specifications, and are in proper - f orm, kind, amount; and quality, and payment therefor is hereby recommended. I SYSTEM ASSIGN REF. NO. DEPT AUTH SIGNATURE" The term "average annual net earnings" means one-half of any netearnings of the business or farm before Federal, State and local taxes during the two taxable years immediately preceding the taxable year in which the business or farm is displaced. "Average annual net earnings" includes any compensation paid by the business or farm to the owner, his spouse or his dependents during the two-year per- iod. Such earnings and compensation may be established by Federal income tax returns filed by the business or farm and its owner, his spouse and his dependents during the two year period: 1, the undersigned, do hereby certify that the above information is true and correct and agree to accept the amount of 8 in lieu of actual moving expenses. I further certify that the business or farm cannot be relocated without a substantial loss of existing patro- nage and is not a part of a commercial enterprise having at least one other establishment which isnot being acquired by the State or the Uni- ted States and which is engaged in the same or similar business. Mail Claim To: Signature Title 2 -2 3--T3 Date FIXED PAYMENT ELIGIBILITY Business Name: Tourdot Custom Upholstery, Inc. Project Site Address: 13985 South Robert Trail, Rosemount, MN There are six special eligibility tests which a business must pass to qualify for a fixed relocation payment based on its net earnings. These tests are listed below. The next page comments on the claimant business's ability to meet each of the criteria. Test 1 The business owns or rents personal property which must be moved in connection with such displacement and for which an expense would be incurred in such move; and the business vacates or relocates from its displacement site. Tourdot Custom Upholstery, Inc. has inventory and equipment at the project site, as shown on the listing provided. ;Tent 2 The business cannot be relocated without a substantial loss of its existing patronage (clientele or net earnings). A business is assumed to_meet_t_lis test. unless the Agency determines that it will not suffer a substantial loss of its existing patronage. Factors Related to Lost Patronage a. The -business has not been -able to find--& _ replacement site in the downtown area similar to its project, and therefore is moving further away, b. There is signage on the building advising of the business's existence. c. Loss of patronageisto be assumed, per the relocation rules. Remarks: It should be noted that the Uniform relocation regulations_ which apply to this project require that patronage be defined, not only as clientele, but also as net income. Therefore, an anticipated loss of income is also a factor to be considered under this test. Test 3 The business is not part of a commercial enterprise having more than three other establishments, which are CONWORTH, INC. not being acquired by the Agency, and which are under the same ownership and engaged in the same or similar business activities. Factors Consistent with Four or Fewer Entities Under the Same Ownership and Engaged in Same or Similar Business Activities a. Tourdot Custom Upholstery, Inc. is the only store of that name in Rosemount or elsewhere as stated by the company president and others involved. b. The owner's notarized statement regarding same is attached at Exhibit 5 Test 4 The business is not operated at a displacement dwelling solely for the purpose of renting such dwelling to others. Tourdot Custom Upholstery, Inc. is not involved in this type of business. j Test 5 The business is not operated at the displacement site solely for the purpose of renting the site to others. Tourdot Custom Upholstery, Inc is not involved in this type of business. Test 6 The business contributed materially to the income of the displaced person during the two taxable years prior to displacement. - Average Gross Receipts (1990 and 1991) $87,282.34 Average Net Income (1990 and 1991) $15,992.65 Remarks: The definition of "contributed materially" found in the relocation regulations is that the business: 1) had average j annual gross receipts of at least $5,000.00; or 2) had average ' annual net earnings of at least $1,000.00; or 3) contributed at least 33-1/3 percent of the owner's average annual gross income. CONWORTH, 1NC. AMOUNT OF FIXED PAYMENT A business qualifying for a fixed business relocation payment can be paid an amount equal to its average annual net earnings for the two taxable years prior to its displacement. However, the payment amount is limited to $20,000.00 if the net earnings average is greater; and the payment is a minimum of $1,000.00 if the average is less. Per the Federal relocation rules: "The average annual net earnings of a business are one-half of its net earnings before Federal, State, and local income taxes during the two taxable years immediately prior to the taxable year in which it was displaced. If the business was not in operation for the full two taxable years prior to displacement, net earnings shall be based on the actual period of operation at the displacement site during the taxable year(s) prior to displacement, projected to an annual rate. Average annual net earnings may be based upon a different period of time when the Agency determines it to be more equitable. Net earnings include any compensation obtained from the business or farm operation by its owner, the owner's spouse, and dependents. The displaced person shall furnish proof of net earnings through income tax returns, certified financial statements or other reasonable evidence which the Agency determines is satisfactory." If the two taxable years prior to displacement are not representative of the business's financial status, then, a different time period can be used. For example, perhaps a business was out -of -operation temporarily because of a fire, or perhaps project activities the past year affected its income. If a business moved early in the calendar year, its financial records for the year just past may not be available. The finances for a business in operation for less than a year can be "extended" for an annual basis utilizing the average monthly net profit or loss. The next page computes the amount of fixed relocation payment for which the claimant business is eligible, given the above factors. CONWORTH, INC. FIXED PAYMENT AMOUNT Business Name: Tourdot Custom Upholstery, Inc. Project Site Address: 13985 South Robert Trail, Rosemount, MN Year of Displacement: 1993 Taxable Fiscal Year 1991 Net Income: ($510.48) Compensation to Owner and Dependents: $16,376.63 Other Adjustments: -0- Net Earnings: $15,866.15 Taxable Fiscal Year 1992 Net Income: $50.33 Compensation to Owner and Dependents: $16,068.05 Other Adjustments: -0- Net Earnings: $16,118.38 Average Net Earnings $15,992.65 Recommended Payment $15,992.65 Documentation Attached: Income Tax Forms and W 2's CONWORTH, INC. Jterm��V■w r U•S� CUtj)U["8(1bt1�:utt-rUtfli R.111coltIO TgX@flitll OMB Ito, ls45oe90 epArlmtnl of thOSI try 1hlttUelldtig ere §0�!;etc, geA thArti to mnf a lure yeti quality td file f eltm 112O.A. �,u f Internal Revenue Service for Caton of year 149tl or lax roar b&ginnlgl OC t.Ob nr ) G V aa...,.....►.,1090,endln September ��1. I9 1 UNJV Use Name t ..., ......: .. r A Check this box 11coip.1, IR3 Tourtfot Custom Upholgtery Inc, 0 Emplophtdanitficailennvmblr a personat service Corp.abtl. —�- 1 slumber, street, end room or l� r•n: , � - - �� 1_0989198 Other- (AJ defined In Temp, .u.. tit 1 I .o. bax, Sea 0816 2 at+nstruc+tonl.) Reaf.fec.1.4e1.4T— wife• 13985 S Robert Trgll a Dateincorporaled se, Instructions) p)ewse 1.0-I2-72 print or Ghy or town. flat#. And ZIP code ypo• Rosemount, IIN. 5506$ o ioialessels(seeSPeeuieMstructbns) • E Check Applicable boxes- (1) Intuit relurn • f Checkmethod ofaccountIng: (1) Cash (3) Cheng#incify) v�-.pfd t2) _ Accrual (�) Olhtr (specify) , ► Is Gross rtcelplJ ar Jolts I o b tHt tlldrn! Ind ltlowlnttJ d p 2 Cost of goods sold (see Instructions) • , t Balanct ► _1 e ._ ci ��p 3 Gross profit (Noe lc less line 2)— E4 Domestic torporation dividends subject to the 70% deduttleh . . . . � � � � 3 ��'•ryL_ S 6 8 Interest . . . • . 4 u6 Gross rents . . , . . . . , . s_ 7 Gross royalties , • 6_ • 7 e Capital gain net Income (attach Schedule D (Form 1120)) • . . . 4 Net gain or (loss) from Form 4797, part it, line 19 (111111th NMI 4797) S - - 10 Other Income (see Instructions) ' ' • . _,4_ 11 Total intome—Add lines 3 throw h 10 . . . • • ' . , • ' • ' ' • • • • , . _!0 12 CORrppnfatton Of officers (see Insirucilont) 11 •.,f�f T 1 r t 12 138 Salaries and wages � � ' r ' r . b 1!!! job! ttkdll L -i (t Balance 1 13C 14 Repall's _ 1 a is ;;.• ,. Bad deb ' 16 tlenls . , 17 Taxes •") • t. , • , ', lt7%''6 vi 18 interest 19 ConirlbullonS (see Instrttetlen! lei 101f, Hml(A11on) t t , 149 20 Depreciation (attach Form 4562) . N 21 Cess depredation claimed tisewF,ere on teiurn r C • �) 218 ,• All, 22 Other deductions (Attach Schedule) — J24 23 Total deductions—Add lin!! 12 through 22. ° 24 Taxable income before net operating loss deduction end ! . . dbdUeti. (tint 11 les! tin! 2) r 29 L"it: A Net operali rTgdoss deduction (selnsl►uclions) 2gA b -S edai dedutllonS see Instructions.)-, , r 26 Taxable Into'" 6--tine 24 less line 25t 2�b 2'3c , , , , , t , 27 total tax (part i, line 7) • , , , 26 29 baymtnid: r '' 27 A 19[89 oveipayn,#nl crediltd l0 1990. 2511o E 6 1990 estimated tax payments . 28ev t ills 1990 rdund applied for an to 4466 JIL V e tax deposited wish form 7004 BA1► �1)d_ V � 281 _ } Cea ( Credit from r#Rulnied Investment enmpanles (,,if Atli ('triol 2439) 2Q1 1} M It Credal for federal tax on lulls (attach form 4136). Se! ln�!;;;vlroh! . 281 —` h 10141 priymZ I—Add lines 26d through 2e& 29 Enler any penally for underpayment of WImated tax—Chock► U1 11 form 2220 • ' • _28h 30 Taft d00—II lire Intal of lines 27 Arid 20 Is targt r than line 29h, enter antounl owed I. atlas. . , , , 29 31 Ovelpayinenl—lf line 2$h IS larger than the total of 110121 Anri 29 + _30 32 Enter 11launt of line 31 you want: Credited to 1991 elilml, �r triter amount overpaid 3I ted IAft ♦ ( flafundld ` 32 Please Under p nelGes ur i rr�urt. I Je0are t'rsl I hAve lxAminad oils itlurn. Incindlnl Actnmpanylrg schtdutes and slalent�ni — beliel, P Is Iru#, couec , And comptell. DldarAhon 61 prepares loth!► Ilion I/xpaylr) N based on ell of which pr�pater has errs knowledge. Sign �• Md in the best of my fie. dg• end Here , SI nalure_ot officer Dale PaidP,#parer f Srgnalure� r ala ('re arerY ♦rrclai t• toll nnmh. CherkI p r Y r tole Ohly firm's name (or yours // S#16employtdyz d f'� Itself emPloyed)and f~,r7/. cSAtrr 'r; , _ address for Paperwork Reduction Act Notice. tee poll p! �i�j t L -i ZIP code 1- 1t c' A,r 44*7V form 1 I M_ -A (t9 ?) orm 1120A(1990) Pae 2' Tax Computation Income tax (see Instructions to figure IM tai). Check this box If th1 carp. I) s gVilifie0 pti)onill sit Vito corp. (sit Insltuelions). to, O :it General business ci edit. Check if hom:Ofam 3800 O form 3461 O form 5881 I r Oform 6411 O form 6165 Cl form 159s �"'' b Credit for riot year minimum tax attach Fon P Y ( Form . ' , ra aai Total credits -Add lines 2a and 2b . . . . ' line I fess Ilne 3 . . , . . . . .. . , . , , . . ARecapture taxes. Check if Ironi:O Form 4255 Elf . trim 861 I , . . . . . . . . . . . . . 5 Alternative minimum tax (attach Form 4626). See Instructions . . , . . , , . . . . . . . . 6 Total tax—Add tines 4 lhrou h 6. Enter here and on line 27 PaRe 1 7 additional Information (See GeneralInstruction F.) J (1) II an amount for cost of goods sold is bnlered on line 2, page 1, Refer to the list In the Instructions and stale the principal: complete (a) through (c): (1) Business activity code no. ► ..... .......`... ................ (2) Business activity 0. .......... ¢ A ! , (3) Product or service ►...... 47 `t 0/4 A—' Ae Fel. . K Did any Individual, partnership, estate, or trust at the end of the tax year own, directly of Indirectly, 50% or more of the corporation'; voting I (a) Purchases (see Instructions). - (a) Additional sec. 263A costs (see instructions —a tach schedule)` _ ,e 'schedule) (c) Oihegos�ss,(VV166sschedule) (2) Do the rules of lection 263A (with resrect to property produced or acquired for resale) apply to Ilia corporation? . . Yes O No G K At any time durinQilia tax year, did you have an Interest In or a signature or other ] authority over a financial account In a foreign country (such as a bank account, ; securities account, or other financial account)? (See General Instruction F lot If 'Yvs.' attach schedule showing namz. addre!s, and identifying 11 -Yes,*'nter the name of the loreign counl y ► ...................... number. Enter the amount of tax-exempt Interest received or accrued during iiia L Enter amount of cash distributions and tire book value of property (other lax year . . . ► ; r than cash) distributions made in this tax year ► $ ( Balance Sheets (a) Beginning oftax (b) End of tax year I Cash . . . . . . . �year 2a Trade notes and accounts receivable . . . . , , , Ir less allovrancc tot bad debts . . . . . . , 3 Inventories . . . . . . . . . , 4 U.S. government obligations . , 5 Tax-exempt securities (see Instructions) _ 6 Other current assets (attach schedule) . 7 loans to stockholders . , , . _ 8 Mortgage and real estate loans . . . . . . .��� �• "• 9a Depreciable, depletable, and Intangible assets . . . . 7•�b CJ ����`i_ b Less accumulated depreciation, depletion, and amortization ( `%� %� iJrz 10 land (net of any antoilizatton) , ... . . , , , , 11 Other assets (attach schedule) . , . , -- 12 Total. assets . . . . . . . %rQ 13 Accounts payable. . . . . . . . . . -3li� -------------._ 3f ?. 14 Other uutenl liabilities (ntlach schedule) . . Z7 � W 15 loans Irom stockholders <v 112- �.� f ill 16 Mortgages, notes, bonds payable. . . . . . in scar . . . . 17 Other liabilities (attach schedule) . . . . . . . . t 1C Capital stock (pie(etted and common stock) rs x 19 Paid -in or capital surplus , . , , . , 20 Retained earnings . N 21 Less cost of treasury stock. . . . . . . . 22 Total liabilities and stockholders' equity per Return (Must be completed by all filers.) Reconciliation of Income per Books With Income 1 Net income per books . . . 2 Federal income tax . . . . . , . 6 Incpme recorded on books this year not included on 3 Excess of capital losses over capital gains . . . this return (itemize) .•............. .......................... 4 Income subject to tax not recorded on books this r I Deductions on this return not charged against book year(ilernize)............................ Income thi; year (ilernize)..................... 5 Expenses recorded on books this year not dedu ted /. Ii Income (lire 24, page 1) Enlrr the sum of lines 1 on this return (rtemlzo) C r, /C. i-k,i / ct I c>2 7_J through 5 less the suer of lines 6 acrd 7 . . . rear-� Tourdot Custom Upholstery Inc, Md;.tiofial Inforfiation h. Page 1, Line 17 Taxes Page 1, Line 22 Other Deductions Fica 1447.13 Advertizing. 65.00 Federal Unempl. 22.71 Auto''Exj)ense (Fuel) 2089.16 State Unempl. 753.10 Auto Expense (Repair 3299.67 Real Estate 1218.78 Bank Charges 151.43 Contract Labor 13705.79 Total 3441.72 Fuel 712.68 General Expense 689.25 Insurance 2376.56' Page 2 Part 1 Line If Legal 6 Acctg. 1332.12 License & Permits 98.50 Earl Tourdot 393 40 0178 Medical Expense 265.71 2695 Bruce Court Office Expense 487.28 Inver Brove, MN. 55075 Power & Lite 1232.19 100% Repair & Maint(Equip.) _ 710.43 Sales Promotion 764.95 Telephone 668.42 Contribution Carryover 3 9=30-90 230.00 Total 211649.14 9-30-91 275.00 Total �. 505+00 Allowable 9-30-91 -0- Contribution carryokea: 505.00 Federal Loss Carryover State Loss Carryover 9-30-87 - r 9-30-88 2043.00 9-30-87 2043.00 - 9-30-89 Used 3326.78 (4925.10) 9-30-88 9-30-89 Used 3-199.78 (5426.10) 1 9-30-90 553.00 9-30-90 636.00 Total 997.68Total 452.68 2 Employer's name, address, and ZIP code un1B uo.1545 aooe - i 6 employee Deceased Pension legal 941 Subtotal Deterred Void �r at3ral, O��fwlst� O Ian rep. emp compensation µ' 1398-55cyut:► ibrt Trail a Inc. O p r 1 7 Allocated tips ;�t+,E'fAOlGlt j ii JJn�3 8 Advance EIC payment ` 9 Federal income tax withheld IO Wages, tips, other compensation i{• y,f, ; �' 8.00 % r 3 to r' id ntif'cation number q ��.l�J Cltga # t Y ��1� �� plover's state LD. number 11 Social security tax withheld 12 Social security wages ` �iL'l��i�i ee's social security number 5.95 ' 'S 47 92 1 ,� <. i 13 Social securitytips 14 Medicare wages and tips r 19 Employee's name, address, and ZIP code 1vilydot: 15 Medicare tax withheld 16 Nonqualified plans +arr� 1.39 �S} ii Zis T3Zl1C(! K,�+c 17 See lnstrs. for Form W2 :�• r , _ 1t,'' 18 Other '`' Irtvor Gnwt h: HN 55077 20 21 + ' r 22 Dependent care benefits 23 Benefits included in Box 10 24- State incomeettax 25 State wage3 tip 1. 26 Name of state ; - 9 27 Local income tax 28 ' e Local wages, lips, � g D etc. 29 Name of locality , Copy D For Employer Form W- L �f Wage and Tax Statement 1991 Department of the Treasury—Internal Revenue Service ' 6 rr r: r 1 Control number 2 Employer's name, address, and ZIP code 0M8 a. 1545-0008 ¢ :.. 6 Statutory Deceased Pension legal 941 Subtotal Deferred r employee plan rep. Void emp. com nsation t . 7 Allocated tips tt i 8 Advance EIC payment f i' 9 Federal income tax withheld 10 Wages, tips, other compensation 3 Employer's ideritificationnumber qP y • • Em to er's state LD. number 11 Social security tax withheld 12 Social security wages , 5 Employee's social security number 13 Social security tips 14 Medicare wages and tips 19 Employee's name, address, and ZIP code 15 Medicare tax withheld 16 Nonqualified plans 17 See Instrs. for Form W-2 18 Other 'ttt t 20 21 i 22 Dependent care benefits 23 Benefits included In Box 10 24 State income tax 25 State wages, tips, etc. 26 Name of state 27 Local income tax 28 Local wages, tips, etc. 29 Name of locality Copy D For Employer �. Department of the Treasury—Internalt Formal-2 Wage and Tax Statement 1991 RevenueService Wage I : Fit MIA I Copy 0 For Employer FwW-2 Wage and Tax Statement 1991 1 Control number I IOMB I No..1545-0008 ,2 Employer's name, address, and ZIP code 6 Statutory Deceased Pension Legal 942 Subtotal Deferred Void employee plan rep. emp. compensation Q– 0 Q 0 0 1:1 0 0 TaJtNJOt Qjstxxl Urholst,:-,►q Inc. 7 Allocated tips, 8 Advance EIC payment Smith Robort 'rrail .13985 R03MMIts M 5500 9 Federal Income tax withheld 10 Wages, tips, other compensation 1096,00 11-1,675-116 3 Employer's identification number 4 Employer's state I.D. number 11 Social security tax withheld 12 Social security wages 41 0989193 ...........61 86851 ............ ........ 909.93 19GW4.77 5 Employee's social security number 13 Social security tips 14 Medicare wages and tips 393 40 0173 1, -0() -.77 19 Employee's name, address, and ZIP code 15 Medicare tax withheld 16 N.onquilified,plans - Earl Jack. Zoux it; 23.27 17 See Instrs. for Form W2 17 See Instrs. for Form W-2 IS Other 296.5 ;;nrua cz&= Inver Grow Hcieits,, HN 5510177 2 0 Z 21 — 22 Dependent care benefits 23 Benefits included in Box 10 24 State Income tax 25 State wages, tips, etc. 26 Name of state 27 Local income tax 28 Local wages, tips, etc. 29 Name of locality .......... .. ..... i4947%46 ......... ........... ........................................... ............. ............. .................... Department of the Treasury—Internef Revenue Service I Control number 1OMBNo. 1545-0008 .2 Employer's name, address, and ZIP code eased Pension Legal - 942 Subtotal Deferred Void 6 emtaplulfreremployeeIanIan rep. emp. compensation 0 --ff ------❑ 0 7 Allocated tips 8 Advance EIC payment Tmm-,k)t CtmItarn Ine. 13985 Smith Rdbert Trail Ros4C'lraa it 55063 9 Federal income tax withheld 10 Wages, tips, other compensation 2LY4.00 11604.77 3 Employer's identification number 4 Employer's state I.D. number 11 Social security tax withheld 12 Social security wages 41 098-919:3 613GS51 ...................... ........... 99.50 19GW4.77 5 Employee's social security number 13 Social security tips 14 Medicare wages and tips 469 92 8571 1, -0() -.77 19 Employee's name, address, and ZIP code 15 Medicare tax withheld 16 Nonqualified plans VUAx.-rly Ljmi Tour%k)t 23.27 17 See Instrs. for Form W2 18 Other 2965 Ntvca Court 1twer Grove Vet-jits, M 55077 20 21 22 Dependent care benefits 23 Benefits included in Box 10 24 State income tax 25 State wages, tips, etc, 26 Name of state t x 27 Local income tax Lo I income 8 Local wag s, tips, etc 28 Local wages, tips, etc. 9 am of locality 29 Name of locality 03.00 ..................... ls6C4.77 ............................................. M ............................ ............................ ............. ............. . ............. ................. .. . i Copy D For Employer form W-2 Wage and Tax Statement 1991 Department of the Treasury—Internal evenue erwc 2OrA U•Sfi CorP("Ubn Ificomn Tax Return OMB l+e,1545.08" ppepArlmtnlof es! heesu IhlItUetldh! Ore !lj4t;die. 966 tho"i to make sure yeu quality to use farm 1120 .a. �j� 1' r Interrnl Revenue rvice tat ealendrar yeat 1990 or tax pilaf blllnnln OC tober l U� 9 Use Nrame 6 .........►..1990, lhdin6 �eP.t. mbar ,±� ,•19 1 tet/// K4, A Check this box Itceip.it IRS Tourdot Custom U holbter Inc -w" • e tmpteye►Mfnnnwnenaumlfr 4'tihit' Ipersonal WACOCorp. label. P __ 3r 41-0989198 (as defined In temp, blhet• Number. Mott. end room at foot$,,,. (I a p.o. bM !H Pala 2 et Instruction!.) ; k'•' nets. see.1.441.4T—. will, 13985 S Robert Trail C Dole Incorporated fee Instructions) 1• please 10-12-72 print at City or (own, Rete, end ZIP code ype° Rosemount, t1N. �50f8 b Tolsie»els (setSpedllelnflrvdtons) ErChheck eppticable bares: (1 ) Initial return eckmethod of accounU (Z! Chante M eddres! rug: (1) Cash (2) Aceroai (31 her (specify) ; , ► 1! atoll leceipil 6t sale! O b L!S! tlldra! !na Inoerintif 1! (jalent e ► _l� ` O a 2 Cost of goods told (see Instructions)rl ,. , , , , ✓.' a. , , . 3 gross profit (line I less line 2) 2 —`—XK f tb 4 Domestic torporetlon dividends subject (e the 70% dtd,Mlelt , K rt. E 8 Interest 4 hK �•+ O a . . . • . . a C 6 Qt0S5 tents , , gross royaltte! . . . 6 Capital gain net Income (attach Schedule 0 (Form 1120)) ' r 9 Net gal" or (IOss) from Form 4797, Part 11, Itne 19 (attach term 4797) 10 _gOther Income (see instructions ' r _ e ) . a • It totaitntome—Add (Ines 3 throw h 10 10-- 12 Compensation of officers (See Instructions) , , , •r Y r 13a Salariessndwages 14 PepsW bLe!ljoblOEMteats "ce Ii. !3e 1, 1s —1A bad debt,:. — . 1 � 16 1s a i hent! . . . r , r . ( , a 16 1f taxes —J . , 1 a ,• , __ 1 e Interest • fit . _1e 19 Contributions (see ins!►Uetlenl tot 1091IIMilltl9n) , 19 20 _l2epr*cialion (attach Form 4562) . r , N T21 Less depreciation claimed elsewhere on return 20 22 Other deductions (attach schedule) 23 total deductions—Add llnel 12 through 22. 22 Z 23 N� ; a 24 Taxable Income before net operating loll deduction end 1pWill deddetfon! (Ilne)1(esl11n6 ��)+ , • 24 r fa 25 List: !Net operating loss deduction (see Instructions) It Special deduttlons see Instruction! 25b 26 Taxable Incoma-_Line 24 less line 25c , , , I 25c 2 total tax (Part I, line 7) . , , 2627 / 2e aaymin{l<: r r: a , a c l 1989 oveipaymentcrtdlledtel990, 2e! r' v b 1990 a stimated f ax paymint! . 2 6 %%/r / FIN, 6 test 1990 refund apptied for on Form 1166 -21L0 d- 6 tax deposited with corm 7004 9a1► 84 r Credit from reguleled investment companle! (allach term 2439) 201 I Credit lot federal tax on fuels (attach Ferns 4136). Selln�s;;;, itoh! . tet f' h total payments—Add lines 28d through 28g 29 tnler any penalty for underpayment Of esllmated lax--Checki l.1 If Corm 222011 attached, 30 tat due—II lire total of lines 27 and 20 It large► then line 28h, enter amount owed . . 31 Ovetpll0ifni—If line 28h It larger than the total of lines 2i err) 3r+ 30 32 lnler irlounl of line 31 you want: Credited l0 1991 es11r meet Amount overpaid 31 ...ed tall► j nefunded � 32 Please Under panelP., of pro u,r, I de--la,e—hove ecAminrd this relurn, Inchrding acrnmpanylt g lthedules and sleltmrnts, rV,d to the bell of my Enmviedge and Witt. Iris true, conecl, and complete. bectarauon 9i preparlr (other ihlnffNpeyer) Is based onell Inlormftion of *htch preonfer hes any knowledge. �. •Sign Here ll SI nature of oliicer Vale tette Paid Preparers s�g�Alure ��_�Z r eta Preparer't socias security number F ►er'! •1-<L?L L - j / o Check IInl t4m'r name or yours seti•empl ed yy: dp0 9 1 If sell tmployed)and , C'%drl, c5'ltrir 'c; address _ E.1, No. F 1 ForP:aperwork Aeductlon Acl Miles, Pale p!r ( Ir a Ir ~f 11pc0de �, ; c�♦.�. n�:�}c 1•�q1� ��t, `►t71� form j20. • >.°1rv,:�;' rJlflr)rr,.�l'rr S.SO�iR .Tourdot Custom Upholstery Inc. ArdiLional Information • Pae 1, Line 17 Taxes Page 1, Line e 22 Other Deductions Fica 1447.13 Advertizing. 65.00 ,. Federal Unempl. 22.71 Auto'Expense (Fuel) 2089.16 _ry.. State Unempl. .753.10 Auto Expense (Repair 3299.67 Real Estate 1218.78 Bank Charges 151.43 IFF _ Contract Labor 13705.79 Total 3441.72 Fuel 712.68 General Expense 689.25 Insurance 2376.56 Page 2 Part 1 Line H Legal & Acctg. 1332.12 License & Permits 98.50 Earl Tourdot 393 40 0178 Medical Expense 265.71 2695 Bruce Court Office Expense 487.28 ` ,,•� Inver Brove, MN. 55075 Power & Lite 1232.19 100% Repair & Maint E ui . P ( q p ) 710..43 Sales Promotion 764.95 s Telephone 668.42 ' Contribution Carryover � 9=30-90 r• 230.00 Total 29649.14 9-30-91 ' 215.00 Total �. 50500 ' . Allowable 9-30-91 -0.. r y. }" Contribution carryokec_ 505.00 l Loss Carryover v State Loss Carryover -9-30-87 2043.00 9-30-81' 2043.00 r�S 9-30-88 3326.78 9-30-88 3199..78 - 9-30-89 Used (4925,10) 9-30-89 Used (5426.10) "9-30-90 553.00 9-30-90 636.00 .i�:. Total 997,68 Total 452.68 Y i R r :F• m� 1 ZooA U.S. corporation Short -Form Income Tax Return OMeNo. 1545-0890 ertmenl of the Treasury Instructions are beparald. Seg therrl td rnaktl., Sdto you qualify to file Pormm 1124-A. (11]� -naraevenue Service For calendar year, 1991 or tart year beginningC.1..,.. 1.., 1991, ending.. ..Z .>3'G, 19 .. iJ�yJ�7 is Erripioyer identnicatlort riUmber ,heck this box ii **** ** ** 5—DIGIT 55016$ ' :om. Is a personal VU 41-0989198 S f= p g 2 S 0 g 1200 M is.) C bate Incorporated service corp. (as tUURbUt CUSTOM UPHOLSTtRY IMC e defined M Temp. � g 1 8 5 $ 1i 0 8 F` �t t TRAIL - 096 aegs. sec. 1.441-4T—see a U S E M U U N t M N 5 5 0 6$ S b total assets (see Specific Instructions) instructions) ► ❑ 41'.• 1 __ - --i Check applicable boxes: (1) ❑ initial return (2) ❑ Change In addreS9 Check method of accounting: (1) ❑ Cash (2) 19 Accrual (3) Other (specify) C• 19 Gross recelpis or sales .3 b Ltss nlum&' and allowances -`� 1; Balance p• 2 Cost of goods sold (see instructions) . , / , . , , . ; 1 d 3 Gross profit. Subtract line 2 from line is , , , , • . , 1 i , , 3 ` � '04Y LJ — 4 Domestic corporation dividends subject to the 70% deduction 4 5 Interest . . . , . , . . . . , 5 � � 8 6 Gross rents , . . , . . . . . . . . . . . r , 7 Gross royalties. . . a . . . • . . . . . . . . . 1 . . . . ... . . 7 8 Capital gain net income (attach Schedule b (Form 1 120)) . 9 Net gain or (loss) from Form 4797, Pari ll, line 18 (attach Form 4797) A 1 _9 10 Other Income (see instructions), , + 10 I i Total Income. Add lines 3 through 10 • • • • 12 Compensation of officers (see InstrbctionS) .II . /' . . A j 12 13a Salaries and wages b Less )obs credit t �-7 c Balance r► 13c 14 Repairs . . . . . . . . . 1 r , , 14 15 Bad debts . . . . . . . . . . . . . . . 15 / . . 18 % 18 Rents, . . . . . n i7 Taxes . . . , . . , 17 �� 31 r. 18- Interest -- 18 d6 E 10 Contributions (sea-tristrucllons for 10% limitation) i9 20 Depreciation (attach Form 4562) . . . . . . . . •20� _--�� 9 C 21 Less depreciation claimed elsewhere on relum . , 21a 21b 4_2 022 Other deductions (attach schedule)_ • . . - • • ..23fd 0 0 23 Total deductions. Add lines 12 through 22 • • • • • • • ' V 24 Taxable Income before net operating lost deduction and special deductions. Subliacl line 23 from line t1 24 c1'O 25 Less: a Net operating loss deduction (see Instructions), 259_ b Special deductions (see instructions). . 25b 25c 20 Taxable Income, Subtract line 25c from line 24 , . . ... , , , , , , 28 i•Z��4� 27 Total tax (frompage2. Pari 1, line 7) J , , , . 27 /W 10-11 28 payments: 9 1990 overpayment credited to s 28a j� y b 1991 estimated tax payments 28b E % C Less 1991 refund applled loe on tart 4466 28C ( I ) Bill 28d d o Tax deposited with Form 7004 . . , , . 288 I Credit from regulated investment companies (attach Form ,2439) . 28f o 0 Credit for Federal tax on fuels (attach Forrri 4136). See Instructions 28 * h Total payments. Add lines 28d through 28g . . . • • - 2811 tg ' ~ 29 lEstimated tax penalty (see page 4 of IrisltUclions). Check it Form 2220 is attached . • • It" ❑ 29 30 Tax due. If the total of lines 27 and 29 Is larger than line 28h, ehter amount owed . , 30 31 Overpayment. it line 28h Is larger than the total of lines 27 and 29, enter amount overpaid 31 32 Enter amount of line 31 you want: Credited to 1992 estimated lax f► 1 Refunded : 1 32 Under penalties or perjury. I declilr9 Ihnt i have ti0mined this ,elurn. Including occompnnying schedurbs hnd einterments. Arid to the best of my knowledge and Please belief, it is true. correct, and complete. beclaretlon of preparer (other than taxpayer) is based on all Information of which preparer has any knowledge. Sign 44, 1 Ai°r r Here '� Signature of ollicer DaloTNIe Prepare"�s b Ip�Check It Preparer's social security number Paid signal,,, yy y Od-O Preparer's Firm's name (or yours Use Onlyif self-employed) end i �'•r: ( t_ fdrt 1 E.I. No. 1` m address , , t n t_Setblcl ZIP code ► __ rot Paperwork Reducllon Act flotice, 9de R 6 1�_p},lige hu d�cit�hs Cal. No. I I 456 Form flMA (is9i) ♦ I • rorm 1120-A (199 { lax ConloutatlolI 1 Income tax (see instructlohs to figure (ha (ax). Check this box it the corp. Is a qualified personal Service corp. (see Instructions) . , . , , , , , . ,• , , , , , ► D 2a General business credit. Check II from: Ll Form 3800 ❑ form 3468 ❑ Form 5884 ❑ Form 6478 ❑ Form 6765 ❑ Form 8586 ❑ Form 8830 ❑ Form 8826 2a b Credit for prior year minimum tax (attach Form 8827) . . , , , , 2b 3 Total credits. Add lines 26 drd 2b . . . . . . . . . . . . . . . . . . . . 4 Subtract line 3 from line 1 , , , , , , , . , , , , , 5 Recapture taxes. Check It from: ❑ Form 4255 ❑ Form 8611 . . . . . , , 6 Alternative minimum tax (attach Form 4626). See instructions . , . , , , I , , 7 Total tax. Add lines 4 through 6. Enter here and on line 27, page I . . 6 Mla Otlier information (See page 15 of the instructions. 1 Refer to the list In the instructions and state the principal: 5a If an amount is entered on line 2, page 1, see the worksheet on page a Business activity code no. `.... 7a4-0.0 ................... 11 for amounts 10 enter below: t b Business activity to.... _. ��1* �/ y If) purchases (see Instructions) c Product or service �.... �U./.a.i•4(z t•'.., (2) Additional sec. 263A costs (see 2 Did any individual, partnersh*esiale, or trust at Nie end o1 the Instructions ' attach schedule) , tax year own, directly or indirectly, 50% or more of the corporation's voting stock? (For rulesof attribution, see section (3) other costs (attach schedule) /0 267(c).) . . . . . . . . . . . f&Yes ❑ No b Do the rules of section 263A (for property produced or acquired for If `Yes," attach schedule showing name, address, and Iden(lfying resale) apply to the corporation? . , , , , . ❑ Yes U& No number. 8 At any time during the tax year, did the corporation have an Interest in or 3 Enter the amount of tax-exempt Interest received or accrued d signature or other authority over a financial account in a foreign country during the tax year , , , , ` $ (such as a bank account, securities account, or other financial account)? (Stye ptigd 15 -o1 Ilia Instructions lot filing requirements for rnrm 4 Enter amount of cash dlMrlbulions and the book value of prop- ID F 90-22.1.), . , . . , . , , , . , ❑ Yes 19 No i 5 8 erly (other than cash) distributions made In this lax year . . . . . . $ It "Yes," enter the name of the I Balance Sheets (a) Beginning of tax year y Q7 i Cash . . . . . . . . . . . . . 2a Trade notes and accounts receivable . . . . , b Less allowance for bdd debts � 1, '. • , " - • • . 3 Inventories , , . • 4 U.S. government obligations . . , , . , , 5 Tax-exempt securilie§ (see Instructions) , 6 Other current assets (attach schedule) , Loans to stockholder§: 8 Mortgage and real eslale loans , . . , , , , , ga Depreciable, depletable, and Intangible assets . . . b Less accumulated depreciation, depletion, and amortization 10 Land (net of any amortization) , , , , , , , , , 11 Other assets (attach schedule) 12 Total assets. r , , . "v 3 ( ) Q _ D D /Z Jr� j_V_ W 0 0 v19 p u) 13 Accounts pnynble . . . . . , . . . , 14 Other cur►enl Ilabllitloh (attach schedule) 15 Loans Irom stockholders . . . . . . 16 Mortgages, notes, bonds payable , , . , , . , 17 Other liabilities (attach schedule) . . , , . , , 18 Capital stock (preferred and common stock) , _ ' (aid in or capital surplus . 20 Retained earnings . . . 21 Less cost of ireastlry stock 22 Total liabilities mid lt stockholders' equy - �%/� ' a � �, /� _ �_ Ary `, (b) Errd of tax year r --- i.2 ©rz or Z c,c' ReCOticiilatiort of Irtrnntis Mime Rnnkn with (tinntnn tint- t]ahrrri tkAuot do ..(,,.,r,iotorl 1— „n ra-, ► i Net Income per books , , 2 Federal Income lnx. . , 3 Excess of capital losses over capital gains. '7 4 Income subject to lax not recorded on books this year (itemize) .......................... 5 Frnrrr^rs rrcmded on hnnl<s (his year not deducted on this relunr(itendze) / A Income recorded on books this year not Included on Ihis return (Itemize) ....... ........... ....... Deductions on this return riot charged against book Income this year (Itemlze)................... .... '$ Income+ (Ilan 24, (ingn 1) 1=111nr thn sum of Iinna 1 ,IluoU h.5 less the sura of lines 6 and 7 "v 3 , .i !+Z CC n.'rvr 6 -tarot rC' f- /.ZO. .., At"), i ..,...,.,.. Ir•. •, /T-ourdoL Custom Upholstery Inc, Page 1, Line 17 Taxes Pica 1641.82 Federal Unempl, 79.01 State Unempl. 139,20 Real Estate 2545,68 Total 440�#JF Page,2 Part 2 Line 2 Earl Tourdot 393 40 0178 2695 -Bruce Court Inver Grove, MN 55075 100% Contribution Carryover 4200.08 9-30-90 230.00 9-31-91 275.00 9-30-92 120,00 Total 625.00 Allowable 9-30-92 -0•- Carryover 625.00 Federal NOL Carryover 4200.08 Labor 9-30-87 2043.00 9-30-88 3326.78 9-30-89 Used (4925&10) 9-30-90 553.00 9-30-91 510.46 Total 1508:16 Additional Information Paae 2 line d(1)(c) Other Costs Supplies 4200.08 Labor 7010.43 Total 11210.51 Page 1 Line 22 Other Deductions Bank Charges - 182.29 Contract Labor 15394.67 Electric Expense 1263470 Repair & Maim. 600.00 t-�:�►, Gatbage Expense 752.28 Neat Expense 677.50 Insurance 2593.90 Legal & Acctg, 867.00 Licenses & Permits 172.00 Medical Expense 148.55 Office Expense 288.49 Salespromotion 672.00 Telephone Expense 795.35 Van Gas Expense 1736.36 Van Repair & Maint. 2390.24' Total Other Deductions 28534.33 State NOL Carryover 9-30-87 2013.00 9-30-88 3199.78 9-30- 89 Used (5426:10) 9-30=90 636.00 9-30-91 614.00 Total 1066.68 Control number Thrs information is being furnished to the Internal Revenue Service. If you are =e� ;. . . required to file a tax return, a negligence penalty or other sanction may be OMB No. 1545-0008 imposed on you it this income is taxable and you fail to report it. 2 . Employer's name, address, and ZIP code 8 Statutory � Deceased Pension Legal 942 . Subtotal Deferred Void , 942 Subtotal Deterred Void emp. NAPO plan rep emo. O compensation 7 Allocated tips 8 Advance EIC payment Tc=101 CU.S tu n U f� iol s tc ry, L 1,c. 139:3 Smith Aoir-rt Trail 8 Advance EIC payment 9 Federal income tax withheld 10 Wages, tips, other compensation 3 .'Employer s dehtllication number Employer's state I.D. number 11 Social ifeuify tax withheld12 5t>1riA SJclrrttyvirages C)IF�h:,?�f5 i 3 EmMidentification;number 4 Employe�s_ state i D. number Social security tax withheld ' rtfn00e laf security. number r. ... 13 Social stiCZSty ,t ps 14 edl6aie ages and tips 19E e, address, and ZIP code " " ' ' 15 Medicare tax withheld 18 gLitlrtiedplans s , Ximberly L. 'RA-tnjOt ' . 19' Employee's name, address, and ZIP code 17 See Ins . foilE6 17 18 Other 2965 Finicca Ccxtrt 18 Nonqualified plans Invar :7ravp )ka>;!its, 114 55071 2905 11,1-1.11•:„ 0,7.tr•L 17 See Instrs. for Box 17 18 Other 55177 20 21 22 Dependent care benefits 23 Benefits included in Box Id 24;- State income tax r 25 State wages; tips, etc. 28 Name of state 27 Local income tax 28 Local wages, tips,, etc. 29 Name of locality ..._ .... `.9r.............. �. ...................................... .... .... ... .......... ._. ... .. Copy„C For EMPLOYEE'S RECORDS (See Notice on back.)Department of the Treasury—Internal Revenue Service t'Form;:W72. Wage and Tax Statement 1992 (Rev. 4-92) I 1 Control number OMB No. 1545-0008 2 Employer's name, address, and ZIP code TOUztiot 0–Mt1--XUpi-KA-,tory, Il -1c. 8 Statutory Deceased Pension Legal employee rep , 942 Subtotal Deterred Void emp. plan Q compensation 13935 `ryult,t 'ober't Trall 7 Allocated tips 8 Advance EIC payment 8 Federal income tax withheld �'''�•'''' 10 Wages lips, other compensation slat ti 73 3 EmMidentification;number 4 Employe�s_ state i D. number Social security tax withheld ' 12 Social security ages7 ,r,, .,r;5 1 ; 1. Em ............ s Social security tips 113 14 Medicare wages -and tips 19' Employee's name, address, and ZIP code Tourlot Medicare tax withheld 18 Nonqualified plans 21 71 2905 11,1-1.11•:„ 0,7.tr•L 17 See Instrs. for Box 17 18 Other 55177 20 z1 22 Dependent care benefits 23 Benefits included in Box 10 24 State income tax 25 State wages, tips, etc. 28 Name of state rr: , .)�Ei�.?'1 ' 27 Local income tax 28 Local wages, tips, etc. 29 Name of locality Copy B To Be Filed With Employee's FEDERAL Tax Return Form W-2 Wage and Tax Statement 1992 (Rev. 4-92) •e 1 , Control number ; t-,'-_, , r,� ._ : ,,., . „�• ..,;, .., .. 1, This information is being furnished to the Internal Revenue Service. If you are �,M y•: , 1 r.t ...,,ta required to file a tax return, a negligence penalty or other sanction may bd 2 Employer's name, address, and ZIP code Tout -dot: Custan U4)hoI lstery, t1C• " OMB No: 1545.0008 im Dosed on you N this income Is taxable and you fail to report k. } 2 , Frin loy�er s name, addressr aid• hIP Bode r : ti! �} . i 6 Statutory Deceased Pension ' Legal 942." Subtotal Deferred Void z a y !)'M ^,tgl L•".. ea:7 •'7 .'.I f'1.• , empbyee plan -1 . rep.. I emp.., , corn ensation' . ;11 _ ,�.tl ;,�.7 PEA ,1 f AlWi tvu t. ni. TI��•�y��¢ OUL `T1! ; ,. UP�1cilsC�rYr,y,.zn ,,mo.r, A 7,Ailocaled tips 8 Advance EIC payments •. . r .. 10 WaJ999.es, tips, ot`h}e'r]compensation , 1393.5 t gwth Robort'-Trai.1 Income tax withheld , 10 Wailes, tips, other other compensation •Federal 3 Employer's identification number 41-J)9-391Q(i a ,V�Up18yeil IbiAlificallo"n' numbdr:Employer's state 1 D. number' " 11 Social ELrUfi t withheld " t 12w,a -duty wagedW. ............................... 1�a, �r1i.`11 6 Employee's social security number 393--40-4117; - 13 Social security tips '�, rt '�Ys�S1JY r ' '� 7 i 1 �1)i�t tt al''E !e (al security number 13 Social Sit Zf1t� t2ps '` tl i 14 edlriaFq Ages and tie ' s•ti n61M �rt..q rii t r > »r..• : A/'t'la 4 :�: t ._ +� .1. .. , . . l.! , 2965 f1t ice cajrt 17 See instrs. for Box 17 18 other l.�2sntr1k r .1 e}addressYand IP ode ;' .I GtPt m nl 16 Medicaretax'withheld 18 gU�lrtl plans 1rll., t rly .L. Tourdot . 1 ,ar rt•' {rr.: 17• See Ins .bit Kx 17 18Other ark •, ..,.. F i -.-' . .. .. .. .'1F - '�96 Court 28 Local wages, lips, etc. i rite' nr --t{nt `B, UCEL�.rt •1• r • -. <i.f - ,� r t .•.• N 1 t "pt, tT .i ,a 1 ..t r .t � I,.: f ..� .'t,•. It ti t' GaYxve •iiei4its,l J44 55077 ,' ," �•,`, ' I'' (`.,.,.. R T- Lie U.1 -A uraa..�--'-----'- '- 21 22 Dependent care benefits 23 .Benefits Includedjrr.BOX 16 241 -;State income tax 1.11 •..tet 25 '.Stale wages, tips, etc. 28 Name of state 27 Local Income tax 28 Local wages, tips,, etc. 29 Name of locality h.:.i r;.,t�.,.r:.;1-- •--1 .., is ,a - . :`• rarf. ..... : . t ., Copy0 For EMPLOYEE'S RECORDS (See Notice on back.) Department o1 the Treasuryinternal. Revenue Service rFort,:W ;2. Wage and Tax Statement - 1992 (Rev. 4-92) .�, f �r L:'t. .•1 1.f•1 IJI 1•')i t,i'r I. .4. i. �t 1 � .. 1 .. .. 1' • 1 _ _ Control number OMB No. 1545-0008 2 Employer's name, address, and ZIP code Tout -dot: Custan U4)hoI lstery, t1C• 8 Statutory Deceased Pension Legal 942 Subtotal Deferred Void employee plan rep emp. compensation 0 ❑ El Q El El p- 7 Allocated tips 8 Advance EIC payment 13935 South Robert Trull 1(CsE'nounts 9 Federal income tax withheld 10 WaJ999.es, tips, ot`h}e'r]compensation 3 Employer's identification number 41-J)9-391Q(i 4 Employer's state I.D. number 6186851 11 Social security tax withheld 017.6> 12 Social securi wages ............................... 1�a, �r1i.`11 6 Employee's social security number 393--40-4117; - 13 Social security tips 14 Medicare wages and tips 1/1 "T )I 71 19` Employee's name, address, and ZIP code Earl 1. ToaLmtlot 15 Medicare tax withheld 18 Nonqualified plans 21It. 51.i 2965 f1t ice cajrt 17 See instrs. for Box 17 18 other Inver GRtave 1104,111tsl, *:'RI 55077 21 22 Dependent care benefits 23 Benefits included in Box 10 24 State income tax -I i Y) 25 State wages, tips, etc. 28 Name of state .. 27 Local income tax 28 Local wages, lips, etc. 29 Name of locality .` 114 � 801.73 ( (`.,.,.. R T- Lie U.1 -A uraa..�--'-----'- '- - - ----- -- 1-•-,-- •- ••.-.� .a' .,v aa,llr ueparunem or me treasury—mternaf Hevenue Service Form W-2 Wage and Tax Statement 1992 (Rev. 4-92) 1. Control number - This information is being furnished to the Internal Revenue Service. It you are required to file a !ax return, a negligence penalty or other sanction may be OMB No. 1545-0008 imposed on you if this income is taxable and you fail to report it. 2 Employer's name, address, and ZIP code 6 Statutory Deceased Pension Legal 942 Subtotal Deferred Void employee plan rep. emp. compensation 0 El 0 _ o 0 0 'TcMaLi1UC l;i.+'�l-cr.;i �.ijrtltlL'�C1�t"S•, L)r�. 7 Allocated tips 8 Advance EIC payment 13*) 2 i Trail 9 Federal income tax withheld 10 Wages, tips, other compensation 3 tmployir s identification numbdi 4 Employer's state 10. number 11 Social Security taz withheld 12 Sbciai sjeurity wages _....,. r.,--. ....... � I ••+ ? r 1 3 Employer's identification number 4 Employer's state I.D number ................................... 5 Employee's social security number Z 17 t 11 Social security tax withheld ] d ••Etnp►oyee "Too! security number 13 Social security) tips 14 )Medicare wifges and tips , EtnploySe:s "e. address, and ZIP code 15 Medicare tax withheld 18 NongUilRied plans ,1ddk;°r'ly L. T(Jt o lot 17 See Instrs. for Box 17 18 Other 17 See instrs: kir 6ox 17 18 Other 2965 1,nire Ccfurt. 21 22 Dependent care benefits inter tJrc=v'.' ►k�i>stt_t;, ;Ed Yi177 !�7ax 25 State wages, lips, etc. i ;, r 1 .7 3 �. --- 20 21 22 Dependent care benefits 23 Benefits included in Box 10 24 State income tax , 25 State wages, tips, etc. 26 Name of state 27 Local income tax 28 Local wages. tips, etc. 29 Name of locality it +�• Copy C For EMPLOYEE'S RECORDS (See Notice on back.) Department of the Treasury -Internal Revenue Service For, W-2 Wage and Tax Statement 1992 (Rev. 4-92) �., 1 Control number OMB No. 1545-0008 2 Employer's name, address, and ZIP code 7 �TOUV1e)t C;tlntt.r,+= i.(jYte)l:arlr_y, ZIK:. 6 Statutory Deceased Pension Legal 942 Subtotal Deterred Void employee Q plan rep eemmp' ❑" Compesation 7 Allocated tipsy 8 Advance EIC payment 1 ' olvru 'Frill !:ra+ t n! t•1t-, ; j±1 rityri'� 9 federal income tax withheld 10 Wages, lips. other compensation 3 Employer's identification number 4 Employer's state I.D number ................................... 5 Employee's social security number Z 17 t 11 Social security tax withheld ] 12 Social security wages 13 Social security tips 14 Medicare wages and lips 71 19 Employee's name, address, and ZIP code Earl .1. t',7. m lot I 15 Medicare tax withheld '> 1 'I . ",:t 16 Nonqualified plans int).) �'7!•`r, r ;,� .r•� 17 See Instrs. for Box 17 18 Other Iriver "?�)v�> '; ,; '=t:�s, J. -r- 55.171 21 22 Dependent care benefits 23 Benefits included in Box 10 !�7ax 25 State wages, lips, etc. i ;, r 1 .7 3 �. --- 26 Name of state , , ..................... 27 Local income tax ........ ...... 28 Local wages, tips. etc ............. .- 29 Name of locality .................... I. - - -- - ••-- ..._.. --'1-Y- - vV---I LOA MULUr11 uepanmem or ine treasury—internal Hevenue Service Form W-2 Wage and Tax Statement 1992 (Rev. 4-92) i i CLAIMANT'S CERTIFICATION I, Earl J. Tourdot, representing Tourdot Custom Upholstery, Inc. do hereby certify that the following statements are true, complete, and correct to the best of our knowledge: 1. That I -am the owner of Tourdot Custom Upholstery, Inc., which business is currently located at 13985 South Robert Trail, Rosemount, Minnesota, and which is being displaced by the Rosemount Port Authority; 2. That neither Tourdot Custom Upholstery, Inc. nor the corporation own or operate more than three other businesses which are the same or similar to the business which is being displaced from 13985 South Robert Trail in Rosemount, Minnesota; and j 3. That the Income Tax Returns and statements for the fiscal years,of 1991 and 1992, made available to Conworth, Inc. to document this relocation claim, accurately reflect the income and expenses of Tourdot Custom Upholstery, Inc. for the years shown, and are true and correct copies of Tourdot Custom Upholstery, Inc 's income tax returns submitted to the Internal Revenue Service for the years shown. Earl J. Tourdot Date Subscribed and Sworn Before Me This 3 n Day of 1 77 199 /NotXry Public _ JACOUELYNE 0. WENTWORTH NOTARY PUBLIC - MINNESOTA HENNEPIN COUNTY MY commission expires 12-28.96 CONWORTH, INC. December 16, 1992 Earl and Karen Tour Tourdot Upholstery 13985 South Robert Rosemount, MN 55068 PS Form 3800, June 1991 RE: Notice of Relocation Eligibility Project Address: 13985 South Robert Trail Rosemount Armory Site Project PID *34-02010-031--60 Dear Mr. and Mrs. Tourdot: F m O° Q M N o�ao w CD b cr, K C �• 03 g 3 it CD 0 �o w o� a do d� .a On October 30, 1992 the Rosemount Port Authority submitted a written offer to buy the building at 13985 South Robert Trail. The building is on the site of the planned -Rosemount Armory Site Project. This is a NOTICE OF RELOCATION ELIGIBILITY. Our records indicate that you are an occupant of this building. To carry out our' plans to develop the Armory Site Project, it will be necessary for you to move. However, YOU DO NOT NEED TO MOVE NOW. You will not be required to move without at least 90 days advance written notice of the date by which you must vacate. And when you do move, you will be entitled to relocation payments and other assistance in accordance with Federal regulations implementing the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (Uniform Act). The effective date of this Notice _is October 30, 1992. You are now eligible for relocation assistance." As an owner of the property, you are eligible to receive a payment for the actual reasonable cost of moving your business. If you meet certain eligibility conditions, you may elect to receive a fixed payment in lieu of a payment for actual moving costs that is based on your average annual net earnings. The minimum fixed payment is $1,000; the maximum is $20,000. I am enclosing a booklet entitled, "Relocation, Your Rights and Benefits." Please read the booklet carefully. It will help you determine which of these payments is most advantageous to you. Redevelopment Acquisition/Relocation m? CONWORTH..y : 4725 Excelsior Blvd. 11 m Suite 200 m Minneapolis, MN 55416 d (612) 929-0044 M m m CL E 0 U December 16, 1992 Earl and Karen Tour Tourdot Upholstery 13985 South Robert Rosemount, MN 55068 PS Form 3800, June 1991 RE: Notice of Relocation Eligibility Project Address: 13985 South Robert Trail Rosemount Armory Site Project PID *34-02010-031--60 Dear Mr. and Mrs. Tourdot: F m O° Q M N o�ao w CD b cr, K C �• 03 g 3 it CD 0 �o w o� a do d� .a On October 30, 1992 the Rosemount Port Authority submitted a written offer to buy the building at 13985 South Robert Trail. The building is on the site of the planned -Rosemount Armory Site Project. This is a NOTICE OF RELOCATION ELIGIBILITY. Our records indicate that you are an occupant of this building. To carry out our' plans to develop the Armory Site Project, it will be necessary for you to move. However, YOU DO NOT NEED TO MOVE NOW. You will not be required to move without at least 90 days advance written notice of the date by which you must vacate. And when you do move, you will be entitled to relocation payments and other assistance in accordance with Federal regulations implementing the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (Uniform Act). The effective date of this Notice _is October 30, 1992. You are now eligible for relocation assistance." As an owner of the property, you are eligible to receive a payment for the actual reasonable cost of moving your business. If you meet certain eligibility conditions, you may elect to receive a fixed payment in lieu of a payment for actual moving costs that is based on your average annual net earnings. The minimum fixed payment is $1,000; the maximum is $20,000. I am enclosing a booklet entitled, "Relocation, Your Rights and Benefits." Please read the booklet carefully. It will help you determine which of these payments is most advantageous to you. Redevelopment Acquisition/Relocation Tourdot Upholstery December 161, 1992 Page 2 I want to make it clear that you are eligible for assistancetohelp you relocate. In addition to relocation payments, counseling and other services are available to you. If you have any questions please call me, your Relocation Counselor. I can be reached at 929-0044 or by writing to meat Conworth, Inc., 4725 Excelsior Boulevard, #200,, St. Louis Park, Minnesota. We will certainly endeavor to answer your questions. Remember, do not move before we have a chance to discuss your eligibility for assistance. Please note also that we willneedtimely advance notice of your move if you apply for reimbursement of your actual moving expenses. This letter is of importance to you and should be carefully filed for safekeeping. Sincerely, Jac 6uelGe Wentworth -- — — Owner/Consultant sl Enclosure CONWORTH, INC. �ur.r I also wish to receive the following services (for an extra. fee): 1. ❑ Addressee's Address 2. Cl Restricted Delivery m Consult postmaster for fee. m IT b. 13 a Q 4b. Service Typ 51 ^ ❑Registered s, {� Certified January 28, 1993 W n - cc /,�/ i sh l �S ❑ Express Mail ap 7. Date of Deli% V ❑ insured o SENDER: ❑ COD • Complete items 1 and/or 2 for additional services. CONWORTI i, `e ar • Complete items 3, and 4a & b. to • Print ycnr name and address on the reverse of this form so that we can Merchandise m return this card to you. 4725 Excelsior Blvd. > • Attach this form to the front of the mailpiece, or on the back if space m does not permit. Suite 200 • Write "Return Receipt Requested" on the mailpiece below the article number Minneapolis, MN 55416 «. • The Return Receipt will show to whom the article was delivered and the date ` delivered. o �ur.r I also wish to receive the following services (for an extra. fee): 1. ❑ Addressee's Address 2. Cl Restricted Delivery m Consult postmaster for fee. m IT b. 13 a Q 4b. Service Typ 51 ^ ❑Registered s, {� Certified January 28, 1993 W n - cc /,�/ i sh l �S ❑ Express Mail ap 7. Date of Deli% V ❑ insured m O: ❑ COD CD , ❑ Return Receipt for 3 Merchandise o a 0 Earl and Karen Tourdc `= 5. Signature (Addressee) S. Addressee's Address (Only if requested c and fee is paid) Tourdot Upholstery W 13985 S. Robert Trail 6. signature (Agent) Rosemount, MN 55068 ; PS Form 3811, December 1991 * u.S.G.P.o.:test-=-WO DOMESTIC Reference: 90 -Day V«..a._,= Llgw%__L,. Address: 13985 S. Robert Trail Rosemount Armory Site Project PID 434-02010-031-60 - - RETURN RECEIPT Dear Mr. and Mrs Tourdot: The Rosemount Port Authority is in the process of purchasing the property at the above -referenced address. You will be required--` to move for these redevelopment activities Th, .� lehter- sh y rare as a -.nir et (_qG)__day- na-t re_...±—n .� u the date by which you will be required to vacate your present location. The Port Authority is notifying you that you must move from the site address by May -1,19.93.-You , will__be ,given_a confl-rmi na nnt-i c You are entitled to re loirati-on bens itz-,-= auam Lf =31 moves prior to the above-mentioned final vacate date. I will continue to work with you on your move. As always we urge you to call me if you should have any questions on relocation. I can be reached at 929-0044. Sincerely, acgtzelne Wentworth Owner/Consult'ant sl Redevelopment Acquisition/Relocation s RELEASE OF PROPERTY This is to notify the Rosemount Port Authority that I, Earl J. Tourdot, representing Tourdot Custom Upholstery, Inc., will be vacating the property at 13985 South Robert Trail, Rosemount, Minnesota, on May 1, 1993, and relinquish all rights to property, real or personal, left at that address. By CON WORTH, INC. RECEIPT FOR RELOCATION INFORMATIONAL BOOKLET Date January 13, 1993 Name Tourdot Custom Upholstery, Inc. Address 13985 South Robert Trail, Rosemount, MN 55068 I have talked with my Relocation Counselor and understand that I may be required to move because of a government -assisted project called the Rosemount Armory Site Project We discussed: 1. Relocation Services Yes X No 2. Financial Benefits Yes X No 3. Claim Documentation Yes X No 4. Grievance Process Yes X No 5.- Information Release- a "--" I have received a copy of the booklet entitled "Relocation, Your Rights and Benefits," printed by the Minnesota Department of Transportation, and and have looked ,it over with my Counselor. I understand that my eligibility for monetary benefits will depend on my cooperation in providing documentationto establish my claim. My signature on this 'receipt does not obligate me in any way. , Tient' Signature r--) CONWORTH, INC. CERTIFICATION OF CLAIM I, the undersigned, do hereby certify the followings 1. That I have personally inspected the business movable p open -aid 'zts --e�at on --claim h€rein = 2. That to the best of my knowledge and belief the statements contained in this report and upon which the opinions herein are based, are true and correct; 3. That this claim has been made in conformity with and is subject to the requirements of the Uniform Relocation Assistance and Real Properties Acquisition Act of 1970, as amended, and the regulations of the Department of Transportation. 4. That neither myself, the company, nor the employees have a present interest or a contemplated interest in the _ business involved or the real property it occupies; and 5. That neither the employment to make the claim nor the compensation for it are contingent upon theamount of eligible relocation compens_ CONWORTH, INC. QUALIFICATIONS Jacquelyne D. Wentworth PROJECT ASSIGNMENTS: Acquisition, Residential and Business Relocation Services EDUCATION: B.A./1969/Criminal Sociology; Minor in Psychology, University of Minnesota Continuing Education Courses sponsored by the International Right of Way Association, DHUD, NAHRO. Private pilot. Certified dance instructor. PROFESSIONAL AFFILIATIONS: International Right of Way Association, Minnesota Chapter 20, Past Chairman of Relocation Committee. Minnesota Chapter of the National Association of Housing Redevelopment Officials. Past Board President for Eastside Neighborhood Services. Counselor at Your Emergency Service. Aircraft Owners and Pilots Association. FORMED CONWORTH, INC.: 1989 "RELATED EXPERIENCE: Minneapolis Housing & Redevelopment Authority (now MCDA) * Residential rdlocation counselor for 6 years. Also training people from other public agencies in Minnesota, as well as Brazil. * Supervisor of'trouble-shooting team _assigned to problem cases for 3 years. 'Y Instrumental in developing E.E.O. policies of Agency; Showcased in training film produced by DHUD. Von -..Klug & Associates, Inc. Consultant for --11 years in residential and business relocation, as well as acquisition. Activities included work with cities, counties and states completing displacement funded by the Department of Housing & Urban Development, the Department of Transportation, the Urban Mass Transit Agency, local tax increment financing, and the Federal Aviation Administration. COMMENTS: Ms.. Wentworth has been a guest speaker for the University of Minnesota Urban StudiesCoursesand the University Women's Auxiliary. She has also participated in instructing classes for local agencies, the Department of Housing & Urban Development (DIIUD), the International Right of Way Association (IRWA) and the National Association of Housing & Redevelopment Officials (NAHRO). CON`VORTH, INC.