Affidavit Verifying Status of Benefit Applicant
Pursuant to the Georgia Security and Immigration Compliance Act (O.C.G.A 50-36-1), effective July 1, 2007, every agency in Fulton
County providing public benefits through any local program is responsible for determining the immigration status of citizen applicants
for said benefits.
By executing this affidavit under oath, as an applicant for benefits, I am stating the following with respect to my application for benefits
from Fulton County Government:
Select one of the below.
_____________________ I am a United States citizen 18 years of age or older;
_____________________ I am a legal permanent resident 18 years of age or older;
_____________________ I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act, Title 8
U.S.C., as amended, 18 years of age or older and lawfully present in the United States. My alien number issued by the U.S.
Department of Homeland Security or other federal immigration agency is ________________________________________.
The undersigned applicant also hereby verifies that he or she has provided at least one secure and verifiable document, as required by
O.C.G.A § 50-36-1(e)(1), with this affidavit.
The secure and verifiable document provided with this affidavit can best be classified as: _____________________________________
(Please enclose legible copy of document with Affidavit.)
In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or
fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. 16-10-20.
Executed in _____________________________(city), ______________________(state).
_________________________________________ _____________________________________ ______________________
Signature of Applicant Printed Name Date
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ______ DAY OF ______________,20_______.
_________________________________ My Commission Expires: _________________________________
NOTARY PUBLIC
Private Employer Affidavit Pursuant To O.C.G.A. § 36-60-6(d)
Effective July 1, 2013, any private company with more than 10 full-time employees, along with every public employer,
regardless of its size, must register with the federal E-Verify program to check the legal status of new hires.
By executing this affidavit, the undersigned private employer verifies it’s compliance with O.C.G.A. § 36-60-6, stating
affirmatively that the individual, firm or corporation has registered with and utilizes the federal work authorization
program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable
provisions and deadlines established in O.C.G.A. § 13-10-90. Furthermore, the undersigned private employer hereby
attests that its federal work authorization user identification number and date of authorization are as follows:
_________________________________ ___________________ ___________________________________
Federal Work Authorization User Identification Number Date of Authorization Name of Private Employer
If your business employs less than ten (10) employees, please check this box and sign below.
By checking this box and signing this form below you are stating affirmatively that your business employs less than ten (10) employees and that your
business is not required to register with and/or utilize the federal work authorization program commonly known as E-Verify.
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on ______, ___, 20__________ in _________________________(city), ______________(state).
_________________________________ ______________________________________
Signature of Authorized Officer or Agent Printed Name of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ______ DAY OF ______________,20_______.
_________________________________ My Commission Expires: _________________________________
NOTARY PUBLIC
**FORM REQUIRED*** This form must be completed in full and returned with your Fulton County Occupational Tax Renewal and payment.
Failure to return the completed Affidavit Verifying Status of Benefit Applicant, Verifiable and Secure Document, and the Private Employer
Affidavit with your renewal and payment will delay the issuance of your occupational certificate.
**REQUIRED**
Avenu Account: _______________
Affidavit Verifying Status of Benefit Applicant
BUSINESS LICENSE RENEWAL APPLICATION
