Tax Certification Affidavit
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1GOVERNMENT OF THE DISTRICT OF COLUMBIA
Office of the Chief Financial Officer
Office of Tax and Revenue
TAX CERTIFICATION AFFIDAVIT
THIS AFFIDAVIT IS TO BE COMPLETED ONLY BY THOSE WHO ARE REGISTERED TO CONDUCT BUSINESS IN
THE DISTRICT OF COLUMBIA.
Date
Authorized Agent
Name of Organization/Entity
Business Address (include zip code)
Business Phone Number
Authorized Agent
Principal Officer Name and Title
Square and Lot Information
Federal Identification Number
Contract Number
Unemployment Insurance Account No.
I hereby authorize the District of Columbia, Office of the Chief Financial Officer, Office of Tax and Revenue to
release my tax information to an authorized representative of the District of Columbia agency with which I am
seeking to enter into a contractual relationship. I understand that the information released will be limited to
whether or not I am in compliance with the District of Columbia tax laws and regulations solely for the purpose of
determining my eligibility to enter into a contractual relationship with a District of Columbia agency. I further
authorize that this consent be valid for one year from the date of this authorization.
I hereby certify that I am in compliance with the applicable tax filing and payment requirements of the District of
Columbia. The Office of Tax and Revenue is hereby authorized to verify the above information with the appropriate
government authorities.
Signature of Authorizing Agent
Title
The penalty for making false statement is a fine not to exceed $5,000.00, imprisonment for not more than 180 days,
or both, as prescribed by D.C. Official Code §47-4106.
________________________________________________________________________________
Office of Tax and Revenue, PO Box 37559, Washington, DC 20013
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