DeKalb County Department of Planning & Sustainability
________________________________ ________________________________________
Business Name License #/Occupation Tax #
Business Occupation Tax Certificate
Alcohol License
AFFIDAVIT VERIFYING STATUS FOR COUNTY PUBLIC BENEFIT APPLICATION
O.C.G.A. § 50-36-1(e)(2)
By executing this affidavit under oath, as an applicant for a Business License / Occupational Tax Certificate as
referenced in O.C.G.A. § 50-36-1, from DeKalb County the undersigned applicant verifies one of the following
with respect to my application for public benefit:
Do not check more than ONE option.
1) I am a United States citizen, 18 years of age or older.
2) I am a legal permanent resident of the United States 18 years of age or older.
3) I am a qualified 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: _______________________________________.
The undersigned applicant also herby verifies that he or she is 18 years of age or older and 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: (i.e. driver’s license, I-551, I-766, Passport, etc.)
_____________________________________________________________________________________________________________________________
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, of the Official Code of the State of Georgia.
Executed on this the ____________day of ____________________, 20________.
__________________________________________________
Signature of Applicant
__________________________________________________
Printed Name of Applicant
____________________________________________________
Applicant Phone Number
SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE ________ DAY OF ___________________, 20____.
______________________________________________
NOTARY PUBLIC
My Commission Expires: _________________
BL Form 101 Revised 6.30.19
