229 Peachtree Street NE
Atlanta, GA 30303-1605
Phone: 404-656-3916
Suite 1000 - International Tower
GREC GREAB Lawful Presence Verification (01 20 12)
Page 2 of 2
Georgia Real Estate Commission
Georgia Real Estate Appraisers Board
www.grec.state.ga.us
Fax: 404-656-6650
verify@grec.state.ga.us
Notarized Affidavit
Section B
Print Full Name
If you currently hold a Georgia Real Estate License, Appraiser Classification, Instructor Approval ,
School Approval, or Appraisal Management Company Registration, please provide the number:
HOW TO FILL OUT THE AFFIDAVIT
Space #1 - For “type of public benefit,” fill in the type of license, registration, permit or approval for which the application is being submitted. (For
example: Real Estate License, Appraiser Classification, etc.)
Space #2 - For “name of government entity,” applicant should fill in one of the following: GREC or GREAB.
Spaces #3 - #5 - 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.
Space #6 - Fill in the alien number issued by the Department of Homeland Security or other federal immigration agency. (ONLY required if applicant is
a qualified alien or non-immigrant under the Federal Immigration and Nationality Act.)
Space #7 - Fill in the type of secure and verifiable document provided with the affidavit. (For example: driver's license, U.S. passport, U.S. military
identification care, U.S. permanent resident card, etc.)
By executing this affidavit under oath, as an applicant for a(n) ____________________ [type of public benefit], as referenced in O.C.G.A. § 50-36-1, from
_________________________ [name of government entity], the undersigned applicant verifies one of the following with respect to my application for a
public benefit:
1) _________ I am a United States citizen.
2) _________ I am a legal permanent resident of the United States.
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.
The secure and verifiable document provided with this affidavit can best be classified as:____________________________________________________
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).
BEFORE ME ON THIS THE
___ DAY OF ___________, 20____ _________________________________________________
________________________ Signature of Applicant
NOTARY PUBLIC
__________________________________________________
My Commission Expires: Printed Name of Applicant
