Final_Tax_Certification_Affidavit-NEW.pdf
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- Attached to
- LENEL ACCESS CONTROL MODERNIZATION AND INFASTRUCTURE UPGRADE SERVICES State and local contract opportunity
- Solicitation number
- 25-S-026
- Issued by
- District of Columbia
About this file
This is a Tax Certification Affidavit from the District of Columbia Office of the Chief Financial Officer, Office of Tax and Revenue, required for contractors seeking to enter into contractual relationships with District of Columbia agencies. The affidavit serves as authorization for the District to verify tax compliance status with the Office of Tax and Revenue and certifies that the applicant organization is in compliance with applicable District tax filing and payment requirements. The form requires completion only by entities registered to conduct business in the District of Columbia and requests information including the authorized agent name, organization name and business address, federal identification number, unemployment insurance account number, square and lot information, contract number, and signatures from both the authorized agent and principal officer.
The affidavit authorization is valid for one year from the date of execution and allows the Office of Tax and Revenue to release tax compliance information solely for the purpose of determining contractual eligibility. False statements on the affidavit carry penalties including fines up to $5,000, imprisonment for up to 180 days, or both, as prescribed by D.C. Official Code 47-4106. This document is a prerequisite certification requirement for the Lenel Access Control Modernization and Infrastructure Upgrade Services contract opportunity at the Walter E. Washington Convention Center, which includes a 35 percent set-aside for Certified Business Enterprises and requires compliance with District tax obligations as a condition of contract award eligibility.
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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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