Department of Insurance, Securities and Banking: Clean Hands Form
Clean Hands Form
Department of Insurance, Securities and Banking
or owe overdue child support in an amount equal
to 60 days or more of support payments.
I understand that if I knowingly falsify this Certification, the Department will move to revoke the license or permit for which I am applying, and to fine me $1,000.00. I further understand that the Department may conduct an investigation to ascertain the veracity of this 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 guaranteed that my license or permit will be approved.