Basic Business License Clean Hands Self-Certification Form printable pdf download

Basic Business License Clean Hands Self-Certification

You must complete, sign, and submit this certification -- with any application for a license, license endorsement, permit or

renewal, under the Clean Hands Before Receiving a License or Permit Act of 1996, effective May 11, 1996 (DC Law 11-118,

DC Official Code (DCOC) § 47-2861 et seq.) as amended, effective October 21, 2000(DC Law 13-183, § 2(b), DC Code § 47-

2861 et. seq.). If you need help with this form, please call (202) 442-4311.

I, _____________________________understand that the District government is prohibited from issuing or reissuing an license

(name)

or permit to an applicant who owes the District more than $100 in debt to it. I certify, as __________________________________,

(owner/partner/corporate officer)

certify that ______________________________________ , trading as ___________________________________________________ at

(business name)

(trade name)

____________________________________________________, using business tax number ___________________________________,

(business address)

(Federal Employment ID/Social Security Number)

does not, as of the date below, owe the District more than $100 in:

Outstanding fines, penalties or interest assessed under these acts or regulations, issued under their authority:

•

Litter Control Administrative Act of 1985, effective March 25, 1986 (DC Law 6-100; DCOC § 8-801et seq.); or

(A)

Illegal Dumping Enforcement Act of 1994, effective May 20, 1994 (DC Law 10-117; DCOC § 8-901et seq.); or

(B)

DC Traffic Adjudication Act of 1978, effective September 12, 1978 (DC Law 2-104; DCOC § 50-2301.01 et seq.); or

(C)

DCRA Civil Infractions Act of 1985, effective October 5, 1985 (DC Law 6-42; DCOC § 2-1801.01 et seq.); or

(D)

DC Taxicab Commission Establishment Act of 1985, effective March 25, 1986 (DC Law 6-97; DCOC § 50-301et seq.); or

(E)

The Compulsory/No-Fault Motor Vehicle Insurance Act of 1982, effective September 18, 1982 (DC Law 4-155; DCOC §

(F)

31-2401et seq.); or

Past due taxes owed under Title 47 of the DCOC; or

•

Past due DC Water and Sewer Authority service charges or fees; or

•

Fines assessed to car dealers under § 2(i) of the DC Revenue Act of 1937, approved August 17, 1937 (50 Stat. 680; DCOC §

•

50-1501.02(i)); or

Parking fines or penalties assessed by a jurisdiction which has a reciprocity agreement with the District.

•

I understand that:

Completing and submitting this form does not guarantee that my application will be approved.

•

DCRA may conduct an investigation to verify the information in this Form.

•

If I knowingly provide false information on this certification, DCRA will move immediately to revoke any license or permit for

•

which I am applying and fine me $1,000 for each.

__________________________________________________________________

_______________

Signature and Title

Date

941 North Capitol Street NE, Washington, DC 20002

Phone: (202) 442-4311

Fax: (202) 442-4523

For Relay Service call 711

Email:

bbl.infocenter@dc.gov

05-31-08

Basic Business License Clean Hands Self-Certification Form

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