Contractor Affidavit under O.C.G.A. § 13-10-91(b)(1)
By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-
91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance
of services on behalf of _________________________ has registered with, is authorized to use and uses 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. § 13-10-91. Furthermore,
the undersigned contractor will continue to use the federal work authorization program throughout the contract
period and the undersigned contractor will contract for the physical performance of services in satisfaction of
such contract only with subcontractors who present an affidavit to the contractor with the information required
by O.C.G.A. § 13-10-91(b). Contractor 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 Contractor
_________________________________
Name of Project
_________________________________
Name of Public Employer
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on __________________, 201__ in ______________________(city), ______(state).
_________________________________
Signature of Authorized Officer or Agent
_________________________________
Printed Name and Title of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ______ DAY OF ______________,201__.
________________________________
NOTARY PUBLIC
My Commission Expires:
_________________________________
(name of public employer)
