Fillable Afdavit of Residency Teachers System of Georgia Retirement

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Afdavit of Residency Teachers System of Georgia Retirement

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Two Northside 75 Suite 100 Atlanta, GA 30318 (404) 352-6500 fax (404) 352-4885 www.trsga.com
To Be Completed by Member -- please print clearly and mail notarized form to TRS.
TRS_11/22/11
__________________________________________________
Signature of Applicant
__________________________________________________
Printed Name of Applicant
Teachers
Retirement
System of
Georgia
Afdavit of Residency
By executing this afdavit under oath, as an applicant for a(n) public retirement system monthly benet payment, as
referenced in O.C.G.A. § 50-36-1, from the Teachers Retirement System of Georgia, the undersigned applicant veries
one of the following with respect to my application for a public benet:
Your Information
Please print or type all
personal information.
Acceptable Forms of ID
Please see the back
of this form for a list of
acceptable forms of
identication.
__________ ____________________________ ________________ __________
Title (Mr, Ms etc.) Last Name First Name Middle Initial
(_______)__________________ ______________________ __________
Phone Number (daytime) Date of Birth (mm/dd/yy) Gender (M or F)
______________________________________________________________________
Street Address (home address)
_________________________ __________ _______________
City State Zip Code
The undersigned applicant also hereby veries that he or she is 18 years of age or older and has provided at least one
secure and veriable document, as required by O.C.G.A. § 50-36-1(e)(1), with this afdavit.
The secure and veriable document provided with this afdavit can best be classied as:
_________________________________________________________________________________________________.
In making the above representation under oath, I understand that any person who knowingly and willfully makes a false,
ctitious, or fraudulent statement or representation in an afdavit shall be guilty of a violation of O.C.G.A. § 16-10-20, and face
criminal penalties as allowed by such criminal statute.
I am a United States citizen.
I am a legal permanent resident of the United States.
I am a qualied alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued
by the Department of Homeland Security or other federal immigration agency.
My alien number issued by the Department of Homeland Security or other federal immigration agency is:
______________________________.
___________________________
Social Security Number
Executed in _______________________ (city), _______________ (state).
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE
________ DAY OF ___________________, 20________
_____________________________________________
NOTARY PUBLIC
My Commission Expires:
Two Northside 75 Suite 100 Atlanta, GA 30318 (404) 352-6500 fax (404) 352-4885 www.trsga.com
TRS_11/22/11
Teachers
Retirement
System of
Georgia
Afdavit of Residency
Secure and Veriable Documents Under O.C.G.A. § 50-36-2
The following list of secure and veriable documents, published under the authority of O.C.G.A. § 50-36-2, contains
documents that are veriable for identication purposes, and documents on this list may not necessarily be indicative of
residency or immigration status.
• A United States passport or passport card [O.C.G.A § 50-36-2(b)(3); 8 CFR § 274a.2].
• A United States military identication card [O.C.G.A § 50-36-2(b)(3); 8 CFR § 274a.2].
• A driver’s license issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico,
Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa,
or the Swain Islands, provided that it contains a photograph of the bearer or lists sufcient identifying information
regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identication
of the bearer [O.C.G.A § 50-36-2(b)(3); 8 CFR § 274a.2].
• An identication card issued by one of the United States, the District of Columbia, the Commonwealth of Puerto
Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American
Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufcient identifying
information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the
identication of the bearer [O.C.G.A § 50-36-2(b)(3); 8 CFR § 274a.2].
• A tribal identication card of a federally recognized Native American tribe, provided that it contains a photograph of
the bearer or lists sufcient identifying information regarding the bearer, such as name, date of birth, gender, height,
eye color, and address to enable the identication of the bearer. A listing of federally recognized Native American
tribes may be found at http://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/TribalDirectory/index.
htm. [O.C.G.A § 50-36-2(b)(3); 8 CFR § 274a.2].
• A United States Permanent Resident Card or Alien Registration Receipt Card [O.C.G.A § 50-36-2(b)(3); 8 CFR §
274a.2].
• An Employment Authorization Document that contains a photograph of the bearer [O.C.G.A § 50-36-2(b)(3); 8 CFR
§ 274a.2].
• A passport issued by a foreign government [O.C.G.A § 50-36-2(b)(3); 8 CFR § 274a.2].
• A Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast Guard [O.C.G.A
§ 50-36-2(b)(3); 8 CFR § 274a.2].
• A Free and Secure Trade (FAST) card [O.C.G.A § 50-36-2(b)(3); 22 CFR § 41.2].
• A NEXUS card [O.C.G.A § 50-36-2(b)(3); 22 CFR § 41.2].
• A Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card [O.C.G.A § 50-36-2(b)(3); 22 CFR §
41.2].
• A driver’s license issued by a Canadian government authority [O.C.G.A § 50-36-2(b)(3); 8 CFR § 274a.2].
• A Certicate of Citizenship issued by the United States Department of Citizenship and Immigration Services
(USCIS) (Form N-560 or Form N-561) [O.C.G.A § 50-36-2(b)(3); 6 CFR § 37.11].
• A Certicate of Naturalization issued by the United States Department of Citizenship and Immigration Services
(USCIS) (Form N-550 or Form N-570) [O.C.G.A § 50-36-2(b)(3); 6 CFR § 37.11].
• In addition to the documents listed herein, if, in administering a public benet or program, an agency is required by
federal law to accept a document or other form of identication for proof of or documentation of identity, that document
or other form of identication will be deemed a secure and veriable document solely for that particular program or
administration of that particular public benet [O.C.G.A § 50-36-2(c)].
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Afdavit of Residency Teachers System of Georgia Retirement

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Completed 8 January 2021

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