By executing this affidavit under oath, as an applicant for a City of Dahlonega, Georgia Business License or
Occupational Tax Certificate, Alcohol License, or other public benefits as referenced on O.C.G.A. Section 50-36-
1, from City of Dahlonega, 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 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:
_______________________________________
Alien Number
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. Section 50-36-1 (e)(l), with this affidavit. The
secure and verifiable document provided with this affidavit can be classified as:
______________________________________
Name of Verifiable Document
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 a affidavit shall be guilty of a violation of O.C.G.A
Section 16-10-20, and face criminal penalties as allowed by such criminal statute.
Executed in Dahlonega, Georgia on this _____________ day of ____________________ 20 ______.
Subscribed and sworn before me on this day of Signature of Applicant:
_______________, 20 ______ ______________________________________
Notary Public: Printed Name:
My Commission Expires ___________________ ______________________________________
*Note: O.C.G.A. 50-36-1 (e) (2) requires that aliens under the Federal Immigration and Nationality Act, Title 8 U.S.C. as
amended, provide their alien registration number. Because legal permanent residents are included in the federal definition
of “alien”, legal permanent residents must also provide their alien registration number. Qualified aliens that do not have
an alien registration number may supply another identifying number below:
_____________________________________________
Document Number
CITY OF DAHLONEGA
465 Riley Road
Dahlonega, Georgia 30533
Phone: 706-482-2706 • Fax: 706-864-4837
PUBLIC BENEFIT AFFIDAVIT
