Medical Cannabis Acknowledgment and Attestation Form – Washington, DC

The Medical Cannabis Acknowledgment and Attestation Form is the DC Alcoholic Beverage and Cannabis Administration (ABCA) form in which the applicant for a medical cannabis business license makes thirteen numbered attestations and acknowledgments, certifies them under penalty of perjury, and has the signature notarized.

ABCA lists it on its page of medical cannabis business license attestation forms as the Acknowledgement and Attestation Form (All license types). The same page lists two other attestation documents, the CBE Annual Personal Income Attestation Form and the Social Equity Applicant Attestation Statement. Those are separate documents; this form is the general one.

By signing, the applicant states, among other things, that:

• it is not a licensed practitioner making medical cannabis patient recommendations, and its authority as a caregiver or qualifying patient has not been revoked by the ABC Board or the Department of Health;
• the entity and its owners do not owe the District more than the amount printed in item 3, and clean hands certifications for the entity and each proposed owner are attached with the application;
• it authorizes ABCA to run a criminal background check once the application is otherwise ready for license acceptance;
• it is the true owner of the business and no straw ownership is involved;
• it accepts the limitation of liability, indemnification and federal prosecution notices.

The form covers cultivation centers, manufacturers, retailers, internet retailers, couriers and testing laboratories. It is not a license and does not approve anything by itself.

The main group is applicants for a medical cannabis business license from ABCA. The form states that it must be signed and notarized as part of the application process by either the President or the Vice President of the corporation. The agency page labels it as the form for all license types, so it applies whether the application is for a cultivation center, manufacturer, retailer, internet retailer, courier or testing laboratory.

Before signing, the signer must be able to attest to each numbered statement. In particular:

• The applicant is not a licensed practitioner making medical cannabis patient recommendations (item 1).
• The applicant's authority to be a caregiver or qualifying patient has not been revoked by the ABC Board or the Department of Health (item 2).
• The entity and all of its owners do not owe the District more than the threshold printed in item 3, and clean hands certifications are attached for the business entity and each proposed owner.
• The applicant is the true and actual owner of the business and is not acting as the agent of anyone not identified in the application (item 8).

The form names no other representative who may sign for the corporation. It also does not replace the other attestation forms ABCA lists, which cover different statements.

Complete this form when you prepare your medical cannabis business license application, because the form says it must be signed and notarized as part of the application process. No separate due date is printed on it, so it travels with the application.

The criminal background check in item 4 comes later: the applicant authorizes ABCA to run it only if ABCA determines the application otherwise qualifies and is ready for license acceptance. That check looks at whether any owner has been convicted, within the three years before the application was filed, of a felony for a crime of violence, gun offense, tax evasion, fraud or credit card fraud.

Have the clean hands certifications for the business entity and each proposed owner ready at the same time, since item 3 says they are attached with the application. For any application deadline, check ABCA's instructions for the license you are seeking.

This form is not filed on its own: it is signed, notarized and submitted as part of the medical cannabis business license application to ABCA. The form prints no separate mailing address, portal or appointment rule, so use the channels ABCA gives for the application itself.

• With the application: attach the signed and notarized form to the application, together with the clean hands certifications for the business entity and each proposed owner, as item 3 states.
• Notarization: the President or Vice President of the corporation signs, and the notary completes the "Subscribed and sworn to before me" block with signature and commission expiration date.
• ABCA office: the form's footer prints the agency address as 899 North Capitol St NE, Suite 4200B, Washington, DC 20009, and the website ABCA.DC.GOV.

The agency page that lists this form is https://abca.dc.gov/publication/medical-cannabis-business-license-attestation-forms. FillingPDF lets you fill out and download the PDF; submission follows the channels above.