City of Chamblee City Hall
5468 Peachtree Rd. | Chamblee, GA 30341 | 770-986-5010| chambleega.gov
S.A.V.E.
AFFIDAVIT
Affidavit Verifying Residency Status of an Applicant as Required by the
Georgia Security and Immigration Compliance Act O.C.G.A. § 50-36-1(e)(2)
This form is required for ALL LICENSES/PERMITS by State Law
By executing this affidavit under oath, as an Applicant, as a City Vendor, or as a Recipient for other public benefit as referenced in the Georgia
Security and Immigration Compliance Act, (O.C.G.A. § 50-36-1), I am stating the following:
□ I am a United States citizen, or
(Must include a copy of either current State Driver’s License, Passport, Military ID, or other approved document*.)
□ I am a legal permanent resident of the United States**, or
(Must include a copy of your Permanent Resident Card or other approved document*.)
□ 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**(Must include a copy your Employment Authorization Card or other
approved document*.)
**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 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:
*A complete list of verifiable documents can be found on the City of Chamblee website under Occupational Tax Certificates or on the Georgia
Attorney General’s website (O.C.G.A. § 50-36-2).
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