DeKalb County Department of Planning & Sustainability
BUSINESS NAME LICENSE #/OCCUPATION TAX #
NUMBER OF EMPLOYEES (COMPANY-WIDE)
PRIVATE EMPLOYER AFFIDAVIT PURSUANT TO O.C.G.A. § 36-60-6(d)
By executing this affidavit under oath, the undersigned private employer verifies one of the following with
respect to its application for a business license, occupational tax certificate, or other document required to
operate a business as referenced in O.C.G.A. § 36-60-6(d):
SECTION 1. Please check only one:
(A) On January 1st of the below-signed year, the individual, firm, or corporation
employed more than ten (10) employees
1
*** If you select Section 1(A), please fill out Section 2 and then execute below.
(B) On January 1st of the below-signed year, the individual, firm, or corporation
employed ten (10) or fewer employees.
*
** If you select Section 1(B), please skip Section 2 and execute Section 3 below.
SECTION 2.
The employer has registered with and utilizes the federal work authorization program in accordance
with the applicable provisions and deadlines established in O.C.G.A. § 36-60-6. The undersigned
private employer also attests that its federal work authorization user identification number and date
of authorization are as follows:
Name of Private Employer
Federal Work Authorization User Identification Number
Date of Authorization
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SECTION 3.
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 and Title of Authorized Officer or Agent
S
UBSCRIBED AND SWORN BEFORE ME
ON THIS THE DAY OF , 20____
.
NOTARY PUBLIC
My Commission Expires:
1
Sec. 15-27 Employee means an individual whose work is performed under the direction and supervision of the employer and whose
employer withholds FICA, federal income tax, or state income tax from such individual's compensation or whose employer issues to
such individual for purposes of documenting compensation a form I.R.S. W-2 but not a form I.R.S. 1099.
BL Form 102 Revised 6.30.19
