tax_certification_affidavit.pdf
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- Solicitation number
- 25-S-011
- 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. The form is designed to authorize the release of tax compliance information to District of Columbia agencies for entities seeking to enter into contractual relationships with the District. The affidavit must be completed only by those registered to conduct business in the District of Columbia and requires information including the authorized agent details, organization name, business address and phone number, principal officer name and title, square and lot information, federal identification number, contract number, and unemployment insurance account number. The authorization remains valid for one year from the date of execution.
The form serves as both an authorization mechanism and a certification of tax compliance, requiring the signatory to certify they are in compliance with applicable District of Columbia tax filing and payment requirements. The Office of Tax and Revenue is authorized to verify this information with appropriate government authorities, and the released information is limited to tax compliance status solely for determining contractual eligibility. The document includes a penalty provision stating that making false statements can result in fines up to $5,000, imprisonment for up to 180 days, or both, as prescribed by D.C. Official Code §47-4106.
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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 .