Government of the District of Columbia
Office of the Chief Financial Officer
Office of Tax and Revenue
Citywide Clean Hands (CCH)
I am hereby requesting a Clean Hands Certificate for the following entity:
Entity Name:
*
Address :
*
FEIN/SSN:
*
Email:
*
Telephone Number:
*
Attach :
If this is a third-party request, please submit a Power of Attorney with this request form. Should you have additional questions, please contact Rhonda Lycorish at (202) 442-6815 or via email Rhonda.Lycorish@dc.gov.
Title:
*
Requestor:
*
Date:
*
Referred By:
*
-- Select --
Alcohol and Beverage Regulation Administration (ABRA)
Department of Consumer and Regulatory Affairs (DCRA)
Department of Employment Services (DOES)
Department of Health - Health Regulation and Licensing Administration (DOH-HRLA)
Department of Insurance Security and Banking (DISB)
Department of Mental Health (DMH)
Department of Motor Vehicle (DMV)
District of Columbia Lottery and Charitable Games Control Board (DCLCGCB)
Office of Contract and Procurement (OCP)
Other
If other; Please specify:
How would you like to receive your certification?
*
Pick-Up
(Get directions)
Mail
CCH requests will be held for thirty (30) days from the date completed. If requests are not picked up within the allotted timeframe you must reapply.
How many copies of the certificate are being requested?
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1
2
3
4
5
6
*