ppt-affidavit-form.pdf (2018)
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BOARD OF PROFESSIONAL RESPONSIBILITY
OF THE
SUPREME COURT OF TENNESSEE
AFFIDAVIT ESTABLISHING COMPLIANCE WITH
PROFESSIONAL PRIVILEGE TAX OBLIGATIONS
Comes now the undersigned attorney, being first duly sworn, and states:
1.
I have been notified by the Board of Professional Responsibility (the Board) pursuant to
Tenn. Sup. Ct. R. 9, § 26, that I was not in compliance with Tennessee Department of Revenue Professional
Privilege Tax obligations as required by Tenn. Code Ann. § 67-4-1701, et seq.
2.
Within thirty (30) days of the issuance of the notice from the Board, I have fully satisfied
all outstanding obligations to the Tennessee Department of Revenue regarding the Professional Privilege
Tax as evidenced by the Letter of Good Standing issued by the Department of Revenue which is attached
hereto.
3.
I have paid the $100.00 delinquency fee assessed by the Board pursuant to Tenn. Sup. Ct.
R. 9, § 26.4 by (check one):
â
â
Payment of the $100.00 fee by credit card using the Boardâs attorney portal
I have included with this affidavit a check in the amount of $100.00 made payable
to the Board of Professional Responsibility.
Witness my hand and seal this the _________ day of ______________________________,
20_____.
________________________________________
Signature
_______________________________________
Printed Name
BPR No. _________________________________
_______________________________________
Address (Street or P. O. Box)
_______________________________________
City, State, Zip Code
Sworn to and subscribed before me on this _________ day of _____________________________,
20_____.
_______________________________________
Notary Public
My Commission Expires: _________________
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