GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of Health Health Regulations and Licensing Administration Pharmaceutical Control CERTIFICATION FORM TO THE APPLICANT: Please read carefully and completely before signing. A false statement on this certification requires that the Department proceed immediately to revoke the license or permit for which you are not applying and fine you $1000.00. This certificate is required by the "CLEAN HANDS BEFORE RECEIVING A LICENSE OR PERMIT ACT OF 1996". (Effective May 11, 1996, D.C. Law 11-118, D.C. Code §47-2861 et seq.) I, PRINT NAME CLEARLY , certify that as of DATE , I do not owe more than $100.00 to the District of Columbia government as a result of: 1. Fines, penalties or interest assessed pursuant to the Litter Control Administration Action of 1985, effective March 25, 1986 (D.C. Code § 6-2901 et seq.); 2. Fines, penalties or interest assessed pursuant to the Illegal Dumping Enforcement Act of 1994, effective May 20, 1994 (D.C. Law 10-117; D.C. Code § 6-2911 et seq.); 3. Fines, penalties or interest assessed pursuant to the Department of Consumer and Regulatory Affair Civil Infractions Act of 1985, effective October 5, 1986 (D.C. Law 6-42; D.C. Code § 62701 et seq.); or 4. Past due taxes. I understand that if I knowingly falsify this Certification, the Department will move to revoke the license or permit for which I am applying, and to fine me $1,000.00. I further understand that the Department may conduct an investigation to ascertain the veracity of this certification. I understand that this Certification is now required as documentation to accompany my application for a license or permit, and that by completing this Certification, I am not guaranteed that my license or permit will be approved. SIGNATURE OF APPLICANT TITLE 899 North Capitol Street, NE 2nd Floor, Washington, D.C. 20002 (202) 724-4900 Fax: (202) 727-8471 150221cs_certification_cleanhands.docx Rev 2/15 American LegalNet, Inc. www.FormsWorkFlow.com