GOVERNMENT OF THE DISTRICT OF COLUMBIA
Office of the Chief Financial Officer
Office of Tax and Revenue
Name of Organization/Entity
Business Address (include zip code)
Business Phone Number(s)
"I hereby authorize the District of Columbia, Office of the Chief Financial Officer, Office of Tax and Revenue;
consent to release my tax information to an authorized representative of the District of Columbia agency from
which I am seeking to enter into a contractual relationship. I understand that the information released under this
consent will be limited to whether or not I am in compliance with the District of Columbia tax laws and regulations
as of the date found on the government request. I understand that this information is to be used 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
The Office of Tax and Revenue is hereby authorized to verify the above information with the appropriate
government authorities. The penalty for making false statements 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.
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.
Principal Officer Name and Title
Square and Lot Information
Federal Identification Number
Unemployment Insurance Account No.
Signature of Authorizing Agent Title
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