GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION FOR OFFICIAL USE ONLY OFFICE OF TAX & REVENUE (OTR) CLEAN HANDS CERTIFICATION ALL INDIVIDUALS THAT HAVE AN OWNERSHIP INTEREST MUST COMPLETE THIS FORM. __________________ SIGNATURE __________________ DATE PLEASE READ CAREFULLY AND COMPLETELY BEFORE SIGNING. A FALSE STATEMENT ON THIS CERTIFICATION REQUIRES THAT THE ADMINISTRATION 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 ACT OF 1996; EFFECTIVE MAY 11, 1996, (D.C. LAW 11118, D.C. OFFICIAL CODE SEC. 47-2861 et seq.) BEFORE YOU ARE ELIGIBLE TO RECEIVE A LICENSE OR PERMIT. I, ____________________________________________________________, as __________________________________________, (Name – Print or Type) (Applicant’s Title) certify that ___________________________________________________________, social security number ____________________ as of this date_________________________, does 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 Administrative Act of 1985, effective March 25, 1986 (D.C. Law 6-100; D.C. Official Code Sec. 8-801 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. Official Code Sec. 8-901 et seq.); 3. Fines, penalties or interest assessed pursuant to the Department of Consumer & Regulatory Affairs Civil Infraction Act of 1985, effective October 5, 1985 (D.C. Law 6-42; D.C. Official Code Sec. 2-1801.01 et seq.); or 4. Past due taxes; 5. Past due District of Columbia Water and Sewer Authority Service Fees; 6. Traffic adjudication fines or penalties; 7. Parking fines or penalties assessed by other jurisdictions, provided, that a reciprocity agreement is in effect between the jurisdiction and the District; 8. Fines assessed to car dealers; and 9. Fines assessed pursuant to the Taxicab and Limousine Commission Establishment Amendment Act of 2004. I understand that if I knowingly falsify this Certification, the Administration will move to revoke the license or permit for which I am applying, and fine me $1,000.00 (one thousand dollars). I further understand that the Administration may conduct an investigation to ascertain the veracity of this certification. I understand that this Certification is 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 ___________________________________________ Print Name/Title ____________________________________________ ABC Application Number ___________________________________________ ABC License Number SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION FOR OFFICIAL USE ONLY OFFICE OF TAX & REVENUE (OTR) BUSINESS ENTITY CLEAN HANDS CERTIFICATION  Seller A. License Number:  Buyer __________________ SIGNATURE __________________ DATE B. FEIN number: PLEASE READ CAREFULLY AND COMPLETELY BEFORE SIGNING. A FALSE STATEMENT ON THIS CERTIFICATION REQUIRES THAT THE ADMINISTRATION PROCEED IMMEDIATELY TO REVOKE THE LICENSE OR PERMIT FOR WHICH YOU ARE NOW APPLYING, AND FINE YOU $1,000.00 (ONE THOUSAND DOLLARS). THIS CERTIFICATION IS REQUIRED BY THE CLEAN HANDS ACT OF 1996; EFFECTIVE MAY 11, 1996, (D.C. LAW 11-118, D.C. OFFICIAL CODE SEC. 47-2861 et seq.) BEFORE YOU ARE ELIGIBLE TO RECEIVE A LICENSE OR PERMIT. I/We certify that the entity does not owe more than $100.00 to the District of Columbia Government as a result of: 10. Fines, penalties or interest assessed pursuant to the Litter Control Administrative Act of 1985, effective March 25, 1986 (D.C. Law 6-100; D.C. Official Code Sec. 8-801 et seq.); 11. 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. Official Code Sec. 8-901 et seq.); 12. Fines, penalties or interest assessed pursuant to the Department of Consumer & Regulatory Affairs Civil Infraction Act of 1985, effective October 5, 1985 (D.C. Law 6-42; D.C. Official Code Sec. 2-1801.01 et seq.); or 13. Past due taxes; 14. Past due District of Columbia Water and Sewer Authority Service Fees; 15. Traffic adjudication fines or penalties; 16. Parking fines or penalties assessed by other jurisdictions, provided, that a reciprocity agreement is in effect between the jurisdiction and the District; 17. Fines assessed to car dealers; and 18. Fines assessed pursuant to the Taxicab and Limousine Commission Establishment Amendment Act of 2004. If applicant is a sole proprietor, the individual must sign, if Partnership, each partner must sign, if Corporation, President or Vice President must sign, if LLC, managing member must sign the below certification. I/We understand that if I knowingly falsify this Certification, the Administration will move to revoke the license or permit for which I am applying, and fine me $1,000.00 (one thousand dollars). I/We further understand that the Administration may conduct an investigation to ascertain the veracity of this certification. I/We 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. Print name Print Title Signature Date signed SPECIAL NOTICE The District of Columbia will provide the appropriate services and auxiliary aids, including sign language interpreters, whenever necessary to ensure effective communication with members of the public who are deaf, hearing impaired or who have other disabilities affecting communications. Requests for services and auxiliary aids should be made at least ten (10) days prior to any scheduled hearing. Please notify the ADA Coordinator at (202) 442-4423. American LegalNet, Inc. www.FormsWorkflow.com