Final_Tax_Certification_Affidavit-NEW.pdf
PDF 94 KB Posted
- Attached to
- REMOVAL, SUPPLY, INSTALLATION, INSPECTION, MAINTENANCE, AND REPAIR OF CENTRIFUGAL CHILLER
- Solicitation number
- 25-S-033
- Issued by
- District of Columbia
About this file
This is a Tax Certification Affidavit form issued by the Government of the District of Columbia, Office of the Chief Financial Officer, Office of Tax and Revenue, for use in the proposed Removal, Supply, Installation, Inspection, Maintenance, and Repair of Centrifugal Chiller project at the Walter E. Washington Convention Center under the Washington Convention and Sports Authority (Events DC). The affidavit is required to be completed only by entities registered to conduct business in the District of Columbia and serves as a prerequisite for contract eligibility. The form authorizes the Office of Tax and Revenue to release tax compliance information to the District of Columbia agency entering into the contractual relationship, with authorization valid for one year from the date of execution. The affidavit requires the authorized agent or principal officer to certify compliance with all applicable District of Columbia tax filing and payment requirements.
Contractors submitting this affidavit must provide their organization name, business address, phone number, federal identification number, unemployment insurance account number, contract number, and square and lot information. The Office of Tax and Revenue is authorized to verify tax compliance status with appropriate government authorities. False statements made on the affidavit carry penalties of up to $5,000 in fines, imprisonment for not more than 180 days, or both, as prescribed by D.C. Official Code 47-4106. This document is a mandatory compliance requirement for the solicitation, which includes a thirty-five percent (35%) set-aside for Certified Business Enterprises as mandated under the Small and Certified Business Enterprise Development and Assistance Amendment Act of 2014.
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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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