Clean Hands Before Receiving a License or Permit Act of 1996
Certification Form

To the Applicant: Please read carefully and completely before signing. A false statement on this certification requires that the department proceed immediately to revoke the license or permit for which you are now applying, and fine you $1,000. This certification is required by the "Clean Hands Before Receiving a License or Permit" act of 1996 (effective May 11, 1996, DC Law 11-118, DC code CODE §47-2861 et seq.).

All Fields Required

I, ,         (name) applying for a , certify that, as of this date, I do not owe more than $100 to the District of Columbia government as a result of: Fines, penalties, or interest assessed pursuant to the Litter Control Administration Action of 1985, effective March 25, 1986 (DC Law 6-100; DC §6-2901 et seq.); Fines, penalties, or interest assessed pursuant to the Illegal Dumping Enforcement Act of 1994, effective May 20, 1994 (DC Law 10-117; DC Code §6-2911 et seq.); Fines, penalties, or interest assessed pursuant to the Department of Consumer and Regulatory Affairs Civil Infractions Act of 1985, effective October 5, 1986 (DC Law 6-42; DC Code §6-2701 et seq.); or Past due taxes. I understand that if I knowingly falsify this Certification, the Department will move to revoke the license or permit for which I am applying, and to fine me $1,000. I further understand that the Department may conduct an investigation to ascertain the veracity of this certification. I understand that this Certification is now required as documentation to accompany my application for a license or permit, and that by completing this Certification, I am not guaranteed that my license or permit will be approved. _____________________________________                        ______________ Signature and Title                                         Date Social Security # Business/Home Address Phone Number For Tax Assistance Call: (202) 442-4TAX (4829)