tax_certification_affidavit.pdf
PDF 94 KB Posted
- Attached to
- CLOSED CAPTION SERVICES
- Solicitation number
- 25-S-067
- 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, required for entities seeking to enter into a contractual relationship with a District of Columbia agency, specifically Events DC for Closed Captioning Services. The affidavit authorizes the Office of Tax and Revenue to release tax compliance information to determine the bidder's eligibility to contract with the District. By completing this form, the authorized agent certifies compliance with all applicable District of Columbia tax filing and payment requirements. The authorization granted through this affidavit remains valid for one year from the date of execution. The form must be completed only by those registered to conduct business in the District of Columbia and requires documentation of the organization's name, business address, phone number, federal identification number, unemployment insurance account number, contract number, and square and lot information.
False statements made on this affidavit carry significant penalties as prescribed by D.C. Official Code 47-4106, including fines up to $5,000, imprisonment for not more than 180 days, or both. The completed form should be submitted to the Office of Tax and Revenue, PO Box 37559, Washington, DC 20013. This document serves as a prerequisite compliance certification and does not address pricing terms, set-asides, funding amounts, or other contract-specific commercial terms, as it functions solely as a tax eligibility verification requirement for District of Columbia contract bidders.
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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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