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OFFICE OF COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER
JRKQ).LQJ, Commissioner
www.oci.ga.gov
Phone: 855-235-5174 Email: GAInslicensing@psionline.com
AGENTS LICENSING
GID-433-AL JUL2019
INSTRUCTIONS FOR NON-RESIDENT INDIVIDUAL APPLICATION
Page 1 of 1
Effective 1-1-2012, submit with the application the Citizenship Affidavit Form GID-276-EN
which is required of persons making application for all licenses in order to comply with the Georgia
Illegal Immigration Reform and Enforcement Act.
• Effective 7-1-2012, all new licenses will be issued on a biennial basis.
• Check or money order must be payable to: PSI Services LLC / Georgia Insurance Department
• Fees for licensure are based on license type/classes requested:
Agent Life, Accident and Sickness: $115
Agent Property Casualty: $115
Agent Variable Product: $115
Agent for Personal Lines: $115
Agent for Credit or Travel Ticket/Travel Accident: $115
* Adjuster: $115
* Public Adjuster: $115
* Workers Compensation Adjuster: $115
* Counselor: $115
Surplus Lines Broker: $615
Ltd. Group Health Counselor $115
FOR AGENTS APPLYING FOR MULTIPLE LINES ON ONE APPLICATION THE FEES ARE AS FOLLOWS:
Agent Life, Accident & Sickness and Property Casualty: $215
Agent Life, Accident & Sickness and Personal Lines: $215
Agent Life, Accident & Sickness and Variable Products: $215
Agent Life, Accident & Sickness, Variable Products and Property Casualty: $315
Agent Property, Casualty and Surplus Lines Brokers: $715
If applying for Variable Products:
- You must also apply or hold a Georgia Life license and
- attach proof of current NASD registration(s) Series 6, 7, IR or GS
*For applicants applying for Adjuster, Workers Compensation Adjuster, Public Adjuster or Counselor
Licenses: You will need to attach a supplement indicating the type of license and line of authority you are
requesting. In lieu of a supplement, you can indicate license type and line of authority requested on
application under #36 'Jurisdiction and Type of License Requested.'
Mailing Instructions:
Regular Mailing Address WITH PAYMENT:
Overnight Mailing Address WITH PAYMENT:
PSI Services LLC
Bank of America
P.O. Box 742983
ATTN: PSI Services LLC Box 742983
Atlanta, GA 30348-2983
6000 Feldwood Road
Atlanta, GA 30349
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
© 2014 National Association of Insurance Commissioners
Page 1 of 5
Uniform Application for
Individual Producer License/Registration
(Please Print or Type)
Demographic Information
Soc. Security Number
- -
If assigned, National Producer Number (NPN)
If applicable, FINRA Individual Central Registration Depository (CRD)
Number
Last Name JR./SR. etc First Name Middle Name
Date of Birth
(month) ___ (day) ___ (year)____
Residence/Home Address (Physical Street) City State Zip Code Foreign Country
Home Phone Number
( ) -
Individual Applicant Email
A
ddress:
Gender (Circle One)
Male Female
Are you a Citizen of the United States? (Check One)
Yes No (If No, of which country are you a citizen?)
(If NO, and this is an application for a Resident License, you must supply proof of eligibility to
work in the U.S.)
Business Entity Name
Business Address (Physical Street) P.O. Box City State Zip Code Foreign Country
Business Phone Number (include
extension)
( ) -
Business Fax Number
( ) -
Business E-Mail Address Business Web Site Address
Applicant’s Mailing Address
P.O. Box City State Zip Code Foreign Country
a. List any other assumed, fictitious, alias, maiden or trade names which you have used in the past.
b. List any trade names under which you are currently doing business or intend to do business.
(May be subject to state approval)
A
g
enc
y
or Business Entit
y
Affiliations
List your Insurance Agency Affiliations: (Complete only if the applicant is to be licensed as an active member of the business entity)
FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________
FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________
FEIN ________________________ NPN ___________________ Name of Agency ___________________________________________________________
Employment History
Account for all time for the past five years. Give all employment experience starting with your current employer working back five years. Include full and part-time
work, self-employment, military service, unemployment and full-time education.
From To
Month Year Month Year
Position Held
Name
City State Foreign Country
Name
City State Foreign Country
Name
City State Foreign Country
Name
City State Foreign Country
(State Use)
7
65
29
15
13 16
25
26
24
35
27
36
34
1
2
4
22
21
20
19
18
28
30
31
32
33
Check appropriate boxes for license requested.
Resident License
Non-Resident License
• Identify Home State: ___ Home State License #: _________
New Application
Additional Line of Authorit
y
3
8
9
10
11
12
17
23
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
© 2014 National Association of Insurance Commissioners
Page 2 of 5
Uniform Application for
Individual Producer License/Registration
Applicant Name: _________________________________________________
Jurisdiction and Type of License Requested
Next to each jurisdiction, check the license type(s) and line(s) of authority for which you are applying.
License Types:
A – Agent
B – Broker
P - Producer
SLP – Surplus Lines Producer
Lines of Authority:
V – Variable
Life/Variable Annuity
L – Life
H – Accident &
Health or
Sickness
P – Property C – Casualty PL – Personal Lines
Limited Lines:
Credit– Credit CR – Car Rental CROP - Crop
T – Travel
S – Surety
O – Other: Specify
Type
License Type Major Lines of Authority Limited Lines of Authority
Jurisdiction
A B P SLP V L H P C PL Credit CR CROP T S O ___________
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VI
VA
VT
WA
WI
WV
WY
37
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com
© 2014 National Association of Insurance Commissioners
Page 3 of 5
Uniform Application for
Individual Insurance Producer License/Registration
Applicant Name: _________________________________________________
Back
g
round
Q
uestions
The Applicant must read the following very carefully and answer every question. All written statements submitted by the Applicant must
include an original signature.
1 a. Have you ever been convicted of a misdemeanor, had a judgment withheld or deferred, or are you currently charged with committing a
misdemeanor?
Yes ___ No___
You may exclude the following misdemeanor convictions or pending misdemeanor charges: traffic citations, driving under the influence
(DUI), driving while intoxicated (DWI), driving without a license, reckless driving, or driving with a suspended or revoked license.
You may also exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court)
1b.
Have you ever been convicted of a felony, had a judgment withheld or deferred, or are you currently charged with committing a felony?
You may exclude juvenile adjudications (offenses where you were adjudicated delinquent in a juvenile court)
If you have a felony conviction involving dishonesty or breach of trust, have you applied for written consent to engage in the business of
insurance in your home state as required by 18 USC 1033?
If so, was consent granted? (Attach copy of 1033 consent approved by home state.)
Yes __ No ___
N/A___ Yes___ No____
N/A___ Yes___ No____
1c. Have you ever been convicted of a military offense, had a judgment withheld or deferred, or are you currently charged with committing a
military offense?
NOTE: For Questions 1a, 1b and 1c, “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury,
having entered a plea of guilty or nolo contendere or no contest, or having been given probation, a suspended sentence, or a fine.
If you answer yes to any of these questions, you must attach to this application:
a) a written statement explaining the circumstances of each incident,
b) a copy of the charging document,
c) a copy of the official document, which demonstrates the resolution of the charges or any final judgment.
Yes __ No ___
2.
Have you ever been named or involved as a party in an administrative proceeding, including FINRA sanction or arbitration proceeding
regarding any professional or occupational license or registration?
Yes ___ No___
“Involved” means having a license censured, suspended, revoked, canceled, terminated; or, being assessed a fine, a cease and desist order, a
prohibition order, a compliance order, placed on probation, sanctioned or surrendering a license to resolve an administrative action.
“Involved” also means being named as a party to an administrative or arbitration proceeding, which is related to a professional or
occupational license, or registration. “Involved” also means having a license, or registration application denied or the act of withdrawing an
application to avoid a denial. INCLUDE any business so named because of your actions in your capacity as an owner, partner, officer or
director, or member or manager of a Limited Liability Company. You may EXCLUDE terminations due solely to noncompliance with
continuing education requirements or failure to pay a renewal fee.
If you answer yes, you must attach to this application:
a) a written statement identifying the type of license and explaining the circumstances of each incident,
b) a copy of the Notice of Hearing or other document that states the charges and allegations, and
c) a copy of the official document, which demonstrates the resolution of the charges or any final judgment.
3. Has any demand been made or judgment rendered against you or any business in which you are or were an owner, partner, officer or
director, or member or manager of a limited liability company, for overdue monies by an insurer, insured or producer, or have you ever
been subject to a bankruptcy proceeding? Do not include personal bankruptcies, unless they involve funds held on behalf of others.
Yes ___ No___
If you answer yes, submit a statement summarizing the details of the indebtedness and arrangements for repayment, and/or type and
location of bankruptcy.
4. Have you been notified by any jurisdiction to which you are applying of any delinquent tax obligation that is not the subject
of a repayment agreement?
Yes ___ No___
If you answer yes, identify the jurisdiction(s): _______________________________________
5. Are you currently a party to, or have you ever been found liable in, any lawsuit, arbitrations or mediation proceeding involving allegations
of fraud, misappropriation or conversion of funds, misrepresentation or breach of fiduciary duty?
Yes ___ No___
38
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
© 2014 National Association of Insurance Commissioners
Page 4 of 5
Uniform Application for
Individual Insurance Producer License/Registration
Applicant Name:
_________________________________________________
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident,
b) a copy of the Petition, Complaint or other document that commenced the lawsuit or arbitration, or mediation proceedings, and
c) a copy of the official documents, which demonstrates the resolution of the charges or any final judgment.
6. Have you or any business in which you are or were an owner, partner, officer or director, or member or manager of a limited liability
company, ever had an insurance agency contract or any other business relationship with an insurance company terminated for any
alleged misconduct?
If you answer yes, you must attach to this application:
a) a written statement summarizing the details of each incident and explaining why you feel this incident should not prevent you
from receiving an insurance license, and
b) copies of all relevant documents.
7. Do you have a child support obligation in arrearage?
If you answer yes,
a) by how many months are you in arrearage?
b) are you currently subject to and in compliance with any repayment agreement?
c) are you the subject of a child support related subpoena/warrant?
(If you answered yes, provide documentation showing proof of current payments or an approved repayment plan from the appropriate
state child support agency.)
8. In response to a “yes” answer to one or more of the Background Questions for this application, are you submitting document(s) to the
NAIC/NIPR Attachments Warehouse?
If you answer yes
Will you be associating (linking) previously filed documents from the NAIC/NIPR Attachments Warehouse to this application?
Note: If you have previously submitted documents to the Attachments Warehouse that are intended to be filed with this application,
you must go to the Attachments Warehouse and associate (link) the supporting document(s) to this application based upon the
particular background question number you have answered yes to on this application. You will receive information in a follow-up
page at the end of the application process, providing a link to the Attachment Warehouse instructions.
Yes ___ No___
Yes ___ No___
________Months
Yes ___ No___
Yes ___ No___
N/A ___ Yes ___ No___
Yes ___ No___
Please note the application may be revised on a bi-annual basis. To ensure you are filing the current version of the application, please
reference the National Insurance Producer Registry web site at www.nipr.com.
© 2014 National Association of Insurance Commissioners
Page 5 of 5
Uniform Application for
Individual Insurance Producer License/Registration
Applicant’s Certification and Attestation
The Applicant must read the following very carefully:
1. I hereby certify that, under penalty of perjury, all of the information submitted in this application and attachments is true and complete. I am aware that
submitting false information or omitting pertinent or material information in connection with this application is grounds for license revocation or denial of
the license and may subject me to civil or criminal penalties.
2. Unless provided otherwise by law or regulation of the jurisdiction , I hereby designate the Commissioner, Director or Superintendent of Insurance, or other
appropriate party in each jurisdiction for which this application is made to be my agent for service of process regarding all insurance matters in the
respective jurisdiction and agree that service upon the Commissioner, Director or Superintendent of Insurance, or other appropriate party of that jurisdiction
is of the same legal force and validity as personal service upon myself.
3. I further certify that I grant permission to the Commissioner, Director or Superintendent of Insurance, or other appropriate party in each jurisdiction for
which this application is made to verify information with any federal, state or local government agency, current or former employer, or insurance company.
4. I further certify that, under penalty of perjury, a) I have no child-support obligation, b) I have a child-support obligation and I am currently in compliance
with that obligation, or c) I have identified my child support obligation arrearage on this application.
5.
I authorize the jurisdictions to which this application is made to give any information concerning me, as permitted by law, to any federal, state or municipal
agency, or any other organization and I release the jurisdictions and any person acting on their behalf from any and all liability of whatever nature by reason
of furnishing such information.
6.
I acknowledge that I understand and will comply with the insurance laws and regulations of the jurisdictions to which I am applying for licensure.
7.
For Non-Resident License Applications, I certify that I am licensed and in good standing in my home state/resident state for the lines of authority requested
from the non-resident state.
8. I hereby certify that upon request, I will furnish the jurisdiction(s) to which I am applying, certified copies of any documents attached to this application or
requested by the jurisdiction(s).
__________________________________________________
Month/Day/Year
_________________________________________________________________
Original Applicant Signature
_________________________________________________________
Full Legal Name (Printed or Typed)
Attachments
The following attachments must accompany the application otherwise the application may be returned unprocessed or considered deficient.
1. For Non-Resident License Applications and unless otherwise noted in the State Matrix of Business Rules, a state will rely on an electronic verification of an
Applicant’s resident license through the NAIC’s State Producer Licensing Database in lieu of requiring an original Letter of Certification from the resident state.
2. Any jurisdiction specific attachments listed in the State Matrix of Business Rules (www.nipr.com).
39
40
OFFICE OF COMMISSIONER OF INSURANCE
COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER
JRKQ).LQJ, Commissioner
2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334
www.oci.ga.gov
ENFORCEMENT
GID-276-EN J8/2019
(replaces GID-235-SF)
Illegal Immigration Reform And Enforcement Act
Notice
This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this
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
-RKQ).LQJ, Commissioner
2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334
www.oci.ga.gov
ENFORCEMENT
GID-276-EN J8/2019
(replaces GID-235-SF)
Illegal Immigration Reform And Enforcement Act
Citizenship Affidavit Form
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 below):
SAFETY FIRE* (specify below):
INDUSTRIAL
Agent
Agency*
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
JRKQ).LQJ, Commissioner
2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334
www.oci.ga.gov
ENFORCEMENT
GID-276-EN J8/2019
(replaces GID-235-SF)
Illegal Immigration Reform And Enforcement Act
Citizenship Affidavit Form
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
JRKQ).LQJ, Commissioner
2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334
www.oci.ga.gov
ENFORCEMENT
GID-276-EN J8/2019
(replaces GID-235-SF)
Illegal Immigration Reform And Enforcement Act
Citizenship Affidavit Form
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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OFFICE OF COMMISSIONER OF INSURANCE JRKQ).LQJ, Commissioner Effective

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Completed 4 September 2020

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