J.6_-_Tax_Certification_Affidavit.pdf

ATTACHMENT J.6

TAX CERTIFICATION AFFIDAVIT

For all bids/offers over 100,000.00, the following affidavit is required:

__________________________________, 20 ______.

I hereby certify that:

1. I have complied with the applicable tax law fillings and licensing requirements of the District of

Columbia.

2. The following information is true and correct concerning the payment of my tax liability:

State:_____________________________ Current Not Current

Unemployment Insurance_______________________ Current Not Current

3. If not current, as checked in Item 2, I am in compliance with a payment agreement with the

Department of Finance and Revenue Yes No, and/or the Department of

Employment Services Yes No.

4. My tax numbers are as follows:

D.C. Employer Tax ID No.: _______________________________________________

Unemployment Insurance Account No.:_______________________________________

D-U-N-S No.:____________________________________________________________

The D.C. Courts is hereby authorized to verify the above information with appropriate Government authorities. Penalty of making false statements is a fine of not more than $1,000.00, imprisonment for not more than one (1) year or both, as prescribed in D.C. Code Sec. 22-2514. Penalty for false swearing is a fine of not more than $2,500.00, imprisonment for not more than three (3) years, or both, as prescribed in

D.C. Code Sec. 22-2513.

Signature of Person Authorized to Sign Title

This Document

Typed or Printed Name

Name of Organization __________________________________________________________

Notary: Subscribed and sworn before me this __day of ________________, 20 at

___________________________ at ___________________________________

Month and Year City and State