GOVERNMENT OF THE DISTRICT OF COLUMBIA  
                                                           Office of the Chief Financial Officer 
                                                                               Office of Tax and Revenue  
                                          
                                                 TAX CERTIFICATION AFFIDAVIT

THIS AFFIDAVIT IS TO BE COMPLETED ONLY BY THOSE WHO ARE REGISTERED TO CONDUCT BUSINESS IN 
THE DISTRICT OF COLUMBIA.

Date

Authorized Agent 
Name of Organization/Entity 
Business Address (include zip code) 
Business Phone Number

Authorized Agent 
Principal Officer Name and Title 
Square and  Lot Information 
Federal Identification Number 
Contract Number 
Unemployment Insurance Account No. 
 
I hereby authorize the District of Columbia, Office of the Chief Financial Officer, Office of Tax and Revenue  to 
release my tax information to an authorized representative of the District of Columbia agency with which I am 
seeking to enter into a contractual relationship.  I understand that the information released  will be limited to 
whether or not I am in compliance with the District of Columbia tax laws and regulations 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 
Columbia. The Office of Tax and Revenue is hereby authorized to verify the above information with the appropriate 
government authorities.   
  
Signature of Authorizing Agent                                                              Title

The penalty for making false statement 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.                                      
                       
________________________________________________________________________________     
                                                   Office of Tax and Revenue, PO Box 37559, Washington, DC 20013