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Clean Hands Certification - District Of Columbia

Clean Hands Certification Form. This is a District Of Columbia form and can be used in Alcoholic Beverage Regulation Administration Statewide .
 Fillable pdf Last Modified 12/14/2015
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GOVERNMENT OF THE DISTRICT OF COLUMBIA ALCOHOLIC BEVERAGE REGULATION ADMINISTRATION FOR OFFICIAL USE ONLY OFFICE OF TAX & REVENUE (OTR) __________________ SIGNATURE __________________ DATE CLEAN HANDS CERTIFICATION ALL INDIVIDUALS THAT HAVE AN OWNERSHIP INTEREST MUST COMPLETE THIS FORM. 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 ONE THOUSAND AND NO/100 DOLLARS ($1,000.00). 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, _________________________________________________________, as __________________________________________, (Name ­ Print or Type) (Applicant's Title) residing at _________________________________________________________, with Social Security Number ____________________, (Home Address) certify that as of this date________________________, I do not owe more than One Hundred and No/100 Dollars ($100.00) to the District of Columbia Government as a result of: 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 District of Columbia Traffic Adjudication Act of 1978, effective September 12, 1978 (D.C. Law 2-104; D.C. Official Code § 50-2301.01 et seq.); 4. 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.); 5. Fines, penalties or interest assessed pursuant to the District of Columbia Taxicab Commission Establishment Act of 1985, effective March 25, 1986 (D.C. Law 6-97; D.C. Official Code § 50-301 et seq.); 6. Fines, penalties or interest assessed pursuant to the Compulsory/No-Fault Motor Vehicle Insurance Act of 1982, effective September 18, 1982 (D.C. Law 4-155; D.C. Official Code § 31-2401 et seq.); 7. Past due taxes; 8. Fines assessed to car dealers pursuant to section 2(i) of the District of Columbia Revenue Act of 1937, approved August 17, 1937 (50 Stat. 680; D.C. Official Code § 50-1501.02(i)); 9. Parking fines or penalties assessed by other jurisdictions, provided, that a reciprocity agreement is in effect between the jurisdiction and the District; 10. Past due District of Columbia Water and Sewer Authority Service charges or fees; or 11. Vehicle conveyance fees, as that term is defined in § 50- 2302.01(i). 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 One Thousand and No/100 Dollars ($1,000.00). 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 _______________________________________ ABC Application Number ___________________________________________ Print Name/Title ___________________________________________ ABC License Number 1. 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
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