Tax Clearance Certificate

TAX CLEARANCE CERTIFICATE

Taxpayer Information

Entity Type

Select entity type (check applicable box). If LLC, indicate classification where applicable.

Taxpayer Identification

Provide either Social Security Number (SSN) or Employer Identification Number (EIN). Do not enter formatting characters.

SSN:     EIN:

Tax Period and Tax Types

Tax Period Covered — From: To:

Purpose of Clearance

Certification and Authorization

I declare, under penalty of perjury, that the information provided in this request is true, complete and correct to the best of my knowledge. By signing below I certify and authorize as follows:

1. I have filed, or caused to be filed, all tax returns required of me for the periods stated above, and I have paid all taxes, interest, penalties and administrative assessments that are due and payable as of the date of this request.
2. I understand that issuance of a tax clearance certificate is subject to verification and may be revoked or amended if subsequent review discloses unpaid liabilities, omissions, or material misstatements.
3. I authorize the tax authority to examine tax account records and to disclose compliance status to persons with a legitimate interest in the clearance, including parties identified in the purpose above.
4. I acknowledge that knowingly making a false statement in this document may result in civil or criminal penalties, including penalties for perjury under applicable law.
5. If this request is submitted by an agent, I certify that the agent is authorized to act on behalf of the taxpayer and I attach documentation evidencing such authority when required.

For Official Use Only

Clearance Determination:

Comments / Conditions:

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