Final_Tax_Certification_Affidavit-NEW.pdf
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- Solicitation number
- 25-S-005
- Issued by
- District of Columbia
About this file
The document is a Tax Certification Affidavit issued by the Government of the District of Columbia's Office of the Chief Financial Officer and Office of Tax and Revenue. This form authorizes the District of Columbia to release tax information for the purpose of determining an organization's eligibility to enter into a contractual relationship with a District of Columbia agency. The affidavit is specifically designed for businesses registered to conduct business in the District of Columbia and requires the authorized agent to certify compliance with local tax filing and payment requirements.
The affidavit includes provisions for the authorized agent to consent to a one-year tax information release, with the understanding that the information will be limited to tax law compliance verification. The document warns of potential penalties for false statements, including a fine up to $5,000.00, imprisonment for up to 180 days, or both, as prescribed by D.C. Official Code §47-4106. The form requires detailed information such as the organization's name, business address, principal officer details, federal identification number, contract number, and unemployment insurance account number, which must be completed by the authorized agent seeking to enter into a contractual relationship with a District of Columbia agency.
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Text version
GOVERNMENT OF THE DISTRICT OF COLUMBIA
Office of the Chief Financial Officer Office of Tax and Revenue
Authorized Agent Name of Organization/Entity Business Address (include zip code) Business Phone Number
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.
TAX CERTIFICATION AFFIDAVIT
Date
Office of Tax and Revenue, PO Box 37559, Washington, DC 20013
THIS AFFIDAVIT IS TO BE COMPLETED ONLY BY THOSE WHO ARE REGISTERED TO CONDUCT BUSINESS IN
THE DISTRICT OF COLUMBIA.
Authorized Agent Principal Officer Name and Title Square and Lot Information Federal Identification Number Contract Number Unemployment Insurance Account No.
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.
GOVERNMENT OF THE DISTRICT OF COLUMBIA
Office of the Chief Financial Officer Office of Tax and Revenue
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.
TAX CERTIFICATION AFFIDAVIT
Office of Tax and Revenue, PO Box 37559, Washington, DC 20013 THIS AFFIDAVIT IS TO BE COMPLETED ONLY BY THOSE WHO ARE REGISTERED TO CONDUCT BUSINESS IN THE DISTRICT OF COLUMBIA.
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.
8.2.1.4029.1.523496.503679
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File details come from the government source that posted it. Updated .