Fillable Form GID-276-EN illegal immigration reform and enforcement act notice

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Form GID-276-EN illegal immigration reform and enforcement act notice

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OFFICE OF COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER
John F. King, Commissioner
2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334
www.oci.ga.gov
ENFORCEMENT
GID-276-EN
JUL2019
Illegal Immigration Reform And Enforcement Act
Notice
document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056.
Affidavit
Notice
In accordance with O.C.G.A. §50-36-1, the Office of Insurance and Safety Fire Commissioner is required to verify
the lawful presence of all new and renewal applicants. Therefore, the following documents must be included
with [a] every new application submitted to this Office, regardless of the citizenship status of the applicant,
AND for [b] every renewal application submitted to this Office thereafter by non-citizen (alien) applicants:
1. A signed and notarized copy of the attached Citizenship Affidavit Form; and
2. A copy of the front AND back of one secure and verifiable identification document. (Attached is a list of
ALL secure and verifiable documents that this Office can accept in order to satisfy this requirement. We
cannot accept any documents that are not included in this list. These documents may be submitted to this
Office electronically.)
All applicants are required to submit LEGIBLE COPIES of these two (2) documents, as set forth in [a]
and/or [b] above, before an application can be processed. If applying on behalf of a business entity, then an
employee or officer of the business entity, who has authority, must complete and submit these documents as set
forth in [a] and/or [b] above. However, if there has been a change in the person who has authority to apply for
licensure on behalf of a licensed business entity, these documents must be completed and submitted by the
individual who currently has authority, regardless of the citizenship status of such individual.
In addition, if you (or, for a business entity, the employer or officer with authority) are not a United States citizen,
we are required by law to verify your immigration status through the Federal Systematic Alien Verification of
Entitlement (SAVE) program.
MAILING INSTRUCTIONS
Submit the two (2) required documents referenced above with your complete application to the email address (if
submitted digitally) OR to the mailing address (if submitted in paper form) specified in the application instructions.
HOW TO FILL OUT THE CITIZENSHIP AFFIDAVIT FORM
In the boxes at the top of the form, indicate in which of the three business types: INSURANCE (for this choice
specify Agent, Agency or Carrier), SAFETY FIRE, or INDUSTRIAL LOAN the affidavit pertains. Indicate the
business name on the line where the asterisk * is applicable to the choice. Also, provide the License #, NAIC# or
Employer ID# if known.
Spaces #1 - #3 – Applicant should put an X in the space that best describes the applicant’s citizenship status. Please
note that applicant should put an X in ONLY ONE of these spaces.
•
If you put an X in Space #2 (legal permanent resident) OR Space #3 (qualified alien or non-
immigrant), then applicant MUST write down the alien number that was issued by the
Department of Homeland Security or other federal immigration agency in the space provided.
Spaces #4 - #5 – Applicant should fill in the city and state in which this affidavit form is being notarized.
AN APPLICATION CANNOT BE PROCESSED IF THE
CITIZENSHIP AFFIDAVIT FORM IS NOT COMPLETELY FILLED OUT.
OFFICE OF COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER
John F. King, Commissioner
2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334
www.oci.ga.gov
ENFORCEMENT
GID-276-EN
JUL2019
Illegal Immigration Reform And Enforcement Act
Citizenship Affidavit Form
This office does not discriminate in employment, programs or services. Disabled persons can contact 404-656-2056 to obtain this document in another format.
Citizenship
Affidavit
This affidavit is provided to satisfy the new or renewal requirements for an application in which one of the following types of business:
INSURANCE (Specify Entity Type): SAFETY FIRE* (Specify Entity Type):
INDUSTRIAL
Individual
Business*
Carrier*
Engineering
Hazardous Materials
LOAN*
Manufactured Housing Safety Engineering
*
If the person providing the affidavit serves as “the designated responsible party” (ex.: owner/operator, partner, executive, etc…)
for one of these business types, please provide the name of the business:
If you know one of the following identifiers, please enter it here:
License #
NAIC #
Employer ID #
O.C.G.A. §50-36-1(e)(2) Affidavit .
By executing this affidavit under oath, as an applicant for a license, certificate, registration,
permit, etc., as referenced in O.C.G.A. §50-36-1, from the Office of Insurance, Safety Fire and
Industrial Loan Commissioner, the undersigned applicant verifies one of the following with
respect to my application for a public benefit:
[Check ONLY ONE of the following:]
1) _________ I am a United States citizen; OR
2) _________ I am a legal permanent resident of the United States; OR
My alien number issued by the Department of Homeland Security or
other federal immigration agency is:___________________________.
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 hereby 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.
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, and face criminal penalties as allowed by such
criminal statute.
Executed in ___________________ (city), __________________(state).
___________________________________
Signature of Applicant
SUBSCRIBED AND SWORN
BEFORE ME ON THIS THE ____________________________________
___ DAY OF ___________, 20___ Printed Name of Applicant
_____________________________
NOTARY PUBLIC
My Commission Expires:
!! SUBMIT ONLY THIS COMPLETED CITIZENSHIP AFFIDAVIT PAGE WITH THE REQUIRED DOCUMENTATION !!
OFFICE OF COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER
John F. King, Commissioner
2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334
www.oci.ga.gov
ENFORCEMENT
GID-276-EN
JUL2019
Illegal Immigration Reform And Enforcement Act
Citizenship Affidavit Form
This office does not discriminate in employment, programs or services. Disabled persons can contact 404-656-2056 to obtain this document in another format.
Citizenship
Affidavit
Sec
u
r
e
and Ve
r
ifi
a
b
le
Documents
Under
O.C.G.A. §
50-36-2
Issued August 1, 2011 by the Office of the Attorney General,
Georgia
The Illegal Immigration Reform and Enforcement Act of 2011 (“IIREA”) provides that “[n]ot
later than August 1, 2011, the Attorney General shall provide and make public on the
Department of Law’s website a list of acceptable secure and verifiable documents. The list shall
be reviewed and updated annually by the Attorney General.” O.C.G.A. § 50-36-2(f). The
Attorney General may modify this list on a more frequent basis, if necessary.
The following list of secure and verifiable documents, published under the authority of O.C.G.A.
§ 50-36-2, contains documents that are verifiable for identification 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 identification 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 sufficient identifying information
regarding the bearer, such as name, date of birth, gender, height, eye color, and address to
enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]
•
An identification 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 sufficient identifying information
regarding the bearer, such as name, date of birth, gender, height, eye color, and address to
enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]
•
A tribal identification card of a federally recognized Native American tribe, provided that
it contains a photograph of the bearer or lists sufficient identifying information regarding
the bearer, such as name, date of birth, gender, height, eye color, and address to enable
the identification of the bearer. A listing of federally recognized Native American tribes
may be found at:
http://www.bia.gov/WhoWeAre/BIA/OIS/TribalGovernmentServices/TribalDirectory/ind
ex.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]
OFFICE OF COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER
John F. King, Commissioner
2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334
www.oci.ga.gov
ENFORCEMENT
GID-276-EN
JUL2019
Illegal Immigration Reform And Enforcement Act
Citizenship Affidavit Form
This office does not discriminate in employment, programs or services. Disabled persons can contact 404-656-2056 to obtain this document in another format.
Citizenship
Affidavit
•
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 Certificate 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 Certificate 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 benefit or
program, an agency is required by federal law to accept a document or other form of
identification for proof of or documentation of identity, that document or other form of
identification will be deemed a secure and verifiable document solely for that particular
program or administration of that particular public benefit. [O.C.G.A. § 50-36-2(c)]
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Completed 5 February 2020

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