Appendix_J_06_-_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 filings 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 This Document Title

Typed or Printed Name

Name of Organization: _____________________________________________

Subscribed and sworn before me this ___ day of ________________, 20 ___, in

City and State ____________________________________________________

Notary Seal ________________________ Notary Public _________________