Department of Insurance, Securities and Banking 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 FOR WHICH YOU ARE NOW APPLYING AND FINE YOU $1,000.00. THIS CERTIFICATION IS REQUIRED BY THE "CLEAN HANDS BEFORE RECEIVING A LICENSE OR PERMIT ACT OF 1996." (EFFECTIVE MAY 11, 1996, DC LAW 11-1118. DC CODE §47-2861 et seq.) Your Name: , Certify that as of (Date), I do not owe more than $100.00 to the District of Columbia government as a result of: Fines, penalties or interest assessed pursuant to the Litter Control Administration Act of 1985, effective March 25, 1986 (DC Law 6-100: DC Code § 6-2901 et seq.); Fines, penalties or interest assessed pursuant to the Illegal Dumping Enforcement Act of 1994, effective May 20, 1994 (DC Law 10-117; DC Code §6-2911 et seq.); Fines, penalties or interest assessed pursuant to the Department of Consumer and Regulatory Affairs Civil Infractions Act of 1985, effective October 5, 1986 (DC Law 6-42: DC Code § 6-2701 et seq.); or Past due taxes 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.