Government of the District of Columbia Department of Insurance, Securities and Banking 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 NOW APPLYING AND FINE YOU $1,000.00. THIS CERTIFICATION IS REQUIRED BY THE "CLEAN HANDS BEFORE RECEIVING A LICENSE OR PERMIT ACT OF 1996." (EFFECTIVE MAY 11, 1996, D.C. LAW 11-1118. D.C. CODE § 47-2861 et seq.) I, _______________________________, Certify that as of ________________________ I do not PRINT NAME CLEARLY A. 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 Act of 1985, effective March 25, 1986 (D.C. Law 6-100: 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 Affairs 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; or B. owe overdue child support in an amount equal to 60 days or more of support payments. 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 by completing this Certification, I am not guaranteed that my license or permit will be approved. ______________________________ SIGNATURE OF APPLICANT ___________________________________ TITLE American LegalNet, Inc. www.FormsWorkFlow.com