tax_certification_affidavit.pdf
PDF 94 KB Posted
- Solicitation number
- 25-S-048
- Issued by
- District of Columbia
About this file
This is a Tax Certification Affidavit issued by the Government of the District of Columbia, Office of the Chief Financial Officer, Office of Tax and Revenue, required for entities seeking to enter into contractual relationships with District of Columbia agencies. The affidavit serves as authorization for the Office of Tax and Revenue to release tax compliance information to District agencies to determine bidder eligibility. The form requires completion by all entities registered to conduct business in the District of Columbia and must be accompanied by authorization from an authorized agent or principal officer, including business address, phone number, Federal Identification Number, Contract Number, Unemployment Insurance Account Number, and Square and Lot Information. The authorization granted through this affidavit remains valid for one year from the date of execution.
By completing and signing this affidavit, the bidder certifies compliance with all applicable District of Columbia tax filing and payment requirements and grants the Office of Tax and Revenue authority to verify this information with appropriate government authorities. The affidavit carries significant legal penalties, with false statements subject to fines not exceeding $5,000, imprisonment for up to 180 days, or both, as prescribed by D.C. Official Code 47-4106. This document is a standard prerequisite for contract eligibility with the District of Columbia and must be submitted as part of the bidding process for the Medical and Infectious Waste Pickup and Disposal Services contract opportunity at the Washington Convention Center.
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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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