Basic Business License Clean Hands Form printable pdf download

Basic Business License

Clean Hands Form

DEPARTMENT OF CONSUMER AND REGULATORY AFFAIRS BUSINESS AND PROFESSIONAL LICENSING

ADMINISTRATION

CLEAN HANDS SELF CERTIFICATION

TO THE APPLICANT: Please read this form carefully and completely before signing. The District government shall not

issue or reissue any license or permit if the applicant owes more than $100.00 in outstanding debt to the District of

Columbia. This certification form is required to be completed and submitted with any application for a license or permit or

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

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

2861 et. seq.).

I, __________________________, as ______________________________ , certify that ________________________

(name)

(owner/partner/corporate officer)

(business name)

trading as ______________________ at _________________________________, using business tax number ______________,

(trade name)

(business address)

(FEIN/SSN)

as of this date, does not owe more than one hundred dollars ($100.00) in outstanding debt to the District of Columbia

government as a result of:

(1)

Fines, penalties or interest assessed pursuant to the Litter Control Administration Act of 1985, effective March 25,

1986 (DC Law 6-100; DC Code Sec. 8-801 (et. seq.) (2001 ed.); or

(2)

Fines, penalties or interest assessed pursuant to the Illegal Dumping Enforcement Act of 1994, effective May 20,

1994 (DC Law 10-117; DC Code Sec. 8-901 (et. seq.) (2001 ed.); or

(3)

Fines, penalties or interest assessed pursuant to the Department of Consumer and Regulatory Affairs Civil Infraction

Act of 1985, effective October 5, 1985 (DC Law 6-42; DC Code Sec. 2-1801.01 (et. seq.) (2001 ed.); or

(4)

Past Due Taxes owed to the Office of Tax and Revenue pursuant to Title 47 of the DC Code; or

(5)

Past due District of Columbia Water and Sewer Authority service fees pursuant to Title 34 Chapter 22 and 24 of the

District of Columbia Code (2001 ed.); or

(6)

Fines, penalties or interest assessed pursuant to Traffic Adjudication Act, Title 50 Chapter 23 of the District of

Columbia Code (2001 ed.).

I understand that a signed and dated Clean Hands Self Certification Form is required as documentation to accompany my

application for a master business license, license endorsements, and permits. I understand that by completing and

submitting this form I am not guaranteed that my license or permit will be approved.

I understand that the Department of Consumer and Regulatory Affairs may conduct an investigation to ascertain the

veracity of the information contained in this Clean Hands Self Certification Form.

I understand that if I knowingly provide false information on this Clean Hands Self Certification Form, the Department of

Consumer and Regulatory Affairs will proceed immediately to revoke each license or permit for which I am applying and

fine me one thousand dollars ($1,000.00).

________________________________________________ ________________ _______________

Signature and Title

FEIN/SSN

Date

For assistance with this form please call (202) 442-4311.

Department of Consumer & Regulatory Affairs

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

12-01-06

Basic Business License Clean Hands Form

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