PRIVATE EMPLOYER AFFIDAVIT
THIS FORM MUST BE COMPLETED. IF YOU SELECT (a), LIST YOUR
FEDERAL WORK PROGRAM AUTHORIZATION IDENTIFICATION
NUMBER AND DATE AUTHORIZED. ALL FORMS MUST BE SIGNED AND
NOTARIZED.
Private Employer Affidavit Pursuant to O.C.G.A. § 36-60-6(d)
By executing this affidavit under oath, as an applicant for a Business License as referenced in O.C.G.A. § 36-60-6(d),
from Greene County, Georgia, the undersigned applicant representing the private employer known as
____________________________________________ verifies one of the following with respect to the application for
the above mentioned document:
(a) _______ The individual, firm, or corporation employs more than ten (10) employees.
(b) _______ The individual, firm, or corporation employs ten (10) or less employees.
If the employer selected (a), please fill out section below.
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(a). The undersigned private employer also
attests that its federal work authorization user identification number (NOT YOUR FEDERAL TAX ID
NUMBER) and date of authorization are as listed below:
_____________________________________________
Federal Work Authorization User Identification Number
_____________________________________________
Date of Authorization
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 allowed by such statute.
Executed on the ___ day of _________, 20____ in ________________________,___________ .
_____________________________________________
Signature of Authorized Officer or Agent
_____________________________________________
Printed Name of and Title of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE ____ DAY OF ______________, 20_____.
______________________________________________
NOTARY PUBLIC
My Commission Expires: _________________________
