Clean Hands Self Certification - District Of Columbia Department Of Health
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1GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF HEALTH
CLEAN HANDS SELF CERTIFICATION
TO THE APPLICANT: Please read carefully and completely before signing. A false statement on this certification requires
that the Department proceed immediately to deny the license for which you are now applying, or revoke a license which you
already have, and fine you $1,000.00. THIS CERTIFICATION is required by the “Clean Hands before receiving a license or
permit Act of 1996” (EFFECTIVE MAY 11, 1996, D.C. LAW 11-118, D.C. CODE §47-2861 et seq.).
I, _______________________________, as ________________________ certify that______________________ as of
Print Name Clearly
(owner/partner/corporate officer)
(Business Name)
trading as____________________ at_______________________, using license #________________________ as of
(Trade Name)
(Business Name)
(DOH License Number)
this date________________, does not owe more than $100.00 in outstanding debt to the District of Columbia as a
(DATE)
result of:
1. Fines, penalties, or interest assessed pursuant to the Litter Control Administration Action of 1985, effective
March 25, 1986 (D.C. Law 6-100; D.C. Code § 6-2901 et seq.);
2. Fines, penalties, or interest assessed pursuant to the Illegal Dumping Enforcement Act of 1994, effective May 20,
1994 (D.C. Law 10-117; D.C. Code § 6-2911 et seq.);
3. Fines, penalties, or interest assessed pursuant to the Department of Consumer and Regulatory Affairs Civil
Infraction Act 1985, effective October 5, 1986 ( D.C. Law 6-42; D.C. Code § 6-2701 et seq.); or
4. Past due taxes owed to the Office of Tax and Revue pursuant to Title 47 of the DC Code; or
5. Past due District of Columbia Water and Sewer Authority services fees pursuant to Title 34 Chapter 22 and 24 of
the DC Code (2001 ed.); or
6. Fines, penalties or interest assessed pursuant to Traffic Adjudication Act, Title 50 Chapter 23 of the DC Code
(2001 ed.).
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 $1,000.00. I further understand that the Department may conduct an investigation to ascertain
the veracity of the information contained in this Clean Hands Self Certification form.
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 OF APPLICANT
TITLE
DATE
RETURN WITH THE APPLICATION TO:
The Department of Health, Health Regulation and Licensing Administration, Intermediate Care Facilities Division, 899
North Capitol Street N.E., Second Floor, Washington, D.C. 20002 Phone (202) 724.8800.
YOU CAN MAKE A DIFFERENCE! Report Violations of fraud, waste, abuse, and mismanagement in DC Government to the
Office of the Inspector General (OIG) by FAXING to OIG at (202) 727-9864 or calling the OIG HOTLINE at (202) 727-0267. All calls are
CONFIDENTIAL.
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