Clean Hands Form
Clean Hands Form. This is a District Of Columbia form and can be use in Blue Sky Secretary Of State.
Tags: Clean Hands Form, CHF, District Of Columbia Secretary Of State, Blue Sky
Basic Business License Clean Hands Form DEPARTMENT OF CONSUMER AND REGULATORY AFFAIRS BUSINESS AND PROFESSIONAL LICENSING ADMINISTRATION CLEAN HANDS SELF CERTIFICATION TO THE APPLICANT: Please read this form carefully and completely before signing. The District government shall not issue or reissue any license or permit if the applicant owes more than $100.00 in outstanding debt to the District of Columbia. This certification form is required to be completed and submitted with any application for a license or permit or renewal by the Clean Hands Before Receiving a License or Permit Act of 1996, effective May 11, 1996 (DC Law 11-118, DC Code Sec. 47-2861 et seq.) as amended, effective October 21, 2000 (DC Law 13-183, sec. 2(b), DC Code sec. 472861 et. seq.). I, __________________________, as ______________________________ , certify that ________________________ (name) (owner/partner/corporate officer) (business name) trading as ______________________ at _________________________________, using business tax number ______________, (trade name) (business address) (FEIN/SSN) as of this date, does not owe more than one hundred dollars ($100.00) in outstanding debt to the District of Columbia government as a result of: (1) (2) (3) (4) (5) (6) Fines, penalties or interest assessed pursuant to the Litter Control Administration Act of 1985, effective March 25, 1986 (DC Law 6-100; DC Code Sec. 8-801 (et. seq.) (2001 ed.); or Fines, penalties or interest assessed pursuant to the Illegal Dumping Enforcement Act of 1994, effective May 20, 1994 (DC Law 10-117; DC Code Sec. 8-901 (et. seq.) (2001 ed.); or Fines, penalties or interest assessed pursuant to the Department of Consumer and Regulatory Affairs Civil Infraction Act of 1985, effective October 5, 1985 (DC Law 6-42; DC Code Sec. 2-1801.01 (et. seq.) (2001 ed.); or Past Due Taxes owed to the Office of Tax and Revenue pursuant to Title 47 of the DC Code; or Past due District of Columbia Water and Sewer Authority service fees pursuant to Title 34 Chapter 22 and 24 of the District of Columbia Code (2001 ed.); or Fines, penalties or interest assessed pursuant to Traffic Adjudication Act, Title 50 Chapter 23 of the District of Columbia Code (2001 ed.). I understand that a signed and dated Clean Hands Self Certification Form is required as documentation to accompany my application for a master business license, license endorsements, and permits. I understand that by completing and submitting this form I am not guaranteed that my license or permit will be approved. I understand that the Department of Consumer and Regulatory Affairs may conduct an investigation to ascertain the veracity of the information contained in this Clean Hands Self Certification Form. I understand that if I knowingly provide false information on this Clean Hands Self Certification Form, the Department of Consumer and Regulatory Affairs will proceed immediately to revoke each license or permit for which I am applying and fine me one thousand dollars ($1,000.00). ________________________________________________ ________________ _______________ Signature and Title FEIN/SSN Date For assistance with this form please call (202) 442-4311. Department of Consumer & Regulatory Affairs 941 North Capitol Street NE, Washington, DC 20002 Phone: (202) 442-4311 Fax: (202) 442-4523 For Relay Service call 711 Email: email@example.com 12-01-06 American LegalNet, Inc. www.FormsWorkflow.com