City of Chamblee City Hall
5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov
Private Employer Affidavit Pursuant to O.C.G.A. §36-60-6(d)
By executing this affidavit under oath, as an applicant for an _____________________________________ as referenced in O.C.G.A. §36-30-6(d),
from the City of Chamblee, the undersigned applicant representing the private employer known as
(Name of Business) verifies one of the following with respect to my application for the above mentioned document:
Section 1:
Choose ONE of the following:
a. On January 1
st
of the below signed year the individual, firm, or corporation employed more than ten (10) employees.
Complete Section 2 and 3 below.
b. On January 1
st
of the below signed year the individual, firm, or corporation employed ten (10) or fewer employees.
Complete 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(a). The undersigned private employer also attests that its federal work authorization user
identification number and date of authorization are as listed below:
Federal Work Authorization User Identification Number Date of Authorization
(This number is between 4-6 digits and does not include letters)
Section 3:
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 violation of O.C.G.A. § 16-10-20, and face criminal penalties allowed by
such statute.
Executed on the date of , 20 in
(city), (state)
Signature of Authorized Officer or Agent
Printed Name of and Title of Authorized Officer or Agent
SCRIBED AND SWORN BEFORE ME ON THIS DAY OF , 20
(Seal)
NOTARY PUBLIC
My Commission Expires:
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