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Clean Hands Form CHF - District Of Columbia
| Clean Hands Form Form. This is a District Of Columbia form and can be used in General Blue Sky Secretary Of State . |
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Government of the District of Columbia Department of Insurance, Securities and Banking Lawrence H. Mirel Commissioner 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 F OR WHICH YOU ARE NOW APPLYING AND FINE YOU $1,000.00. THIS CERTIF ICATION IS REQUIRED BY THE CLEAN HANDS BEFORE RECEIVING A LICENSE OR PE RMIT ACT OF 1996. (EFFECTIVE MAY 11, 1996, D.C. LAW 11-1118. D.C. CODE 47-2 861 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 resul t of: 1. Fines, penalties or interest assessed pursuant to the Litter Control Adm inistration 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 En forcement 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 Cons umer and Regulatory Affairs Civil Infractions Act of 1985, effective October 5, 1986 (D.C. Law 6-42; D.C. Code 6- 2701 et seq.); or 4. Past due Taxes; or B. owe overdue child support in an amount equal to 60 days or more of suppo rt payments. I understand that if I knowingly falsify this Certification, the Departm ent will move to revoke the license or permit for which I am applying, and to fine me $1,000.00. I f urther understand that the Department may conduct an investigation to ascertain the veracity of thi s 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 g uaranteed that my license or permit will be approved. SIGNATURE OF APPLICANT TITLE 810 First Street, NE, 6 FloorWashington, DC20002Tel: (202) 442-4934Fax: (202) 442-8661th maurice.goff@dc.gov American LegalNet, Inc. www.USCourtForms.com
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