Gpsc Form 200-1 - Payphone Service Provider Registration September 2007 (Page 5 of 5) in pdf

Gpsc Form 200-1 - Payphone Service Provider Registration September 2007 Page 5

AFFIDAVIT 3 – FAMILY VIOLENCE SHELTER CONFIDENTIALITY ACT

Personally

appeared

before

me,

officer

duly

authorized

administer

oaths,

______________________, who, after being duly sworn, deposes and says that he or she is

_____________________________________________ of Applicant, certified telephone service provider or

directory information provider.

I make this affidavit on the basis of my personal knowledge.

I have read the May 13, 2005 Order and the August 30, 2005 Amendatory Order in Georgia Public Service

Commission (“Commission”) Docket No. 19553-U, Implementation of Senate Bill 147, the Family Violence Shelter

Confidentiality Act of 2004 (O.C.G.A. § 46-5-7). I have also read the Commission Staff Memorandum dated May 1, 2007 (see

“Addendum – Family Violence Shelter Confidentiality Act”) that summarizes the requirements under O.C.G.A. § 46-5-7 and

the Commission orders issued pursuant to that Code Section of providers of telephone service in the State of Georgia or any

other entity that publishes, disseminates, or otherwise provides telephone directory information or listings of telephone

subscribers in the State of Georgia.

The Applicant agrees that it will satisfy the minimum requirements set forth in the Commission orders and Staff

Memorandum referenced in paragraph 2 of this affidavit to protect the confidentiality of the location and address of family

violence shelters in the State of Georgia.

Pursuant to O.C.G.A. § 46-5-7, the Applicant submits this affidavit as its plan to protect the confidentiality of the

location and address of family violence shelters in the State of Georgia.

FURTHER AFFIANT SAITH NOT.

___________________________________

(COMPANY)

___________________________________

(SIGNATURE)

Subscribed and sworn before me this

(SEAL)

_________ day of_______________, 20_____.

_______________________________________

(NOTARY PUBLIC)

GPSC FORM 200-1, Revised: 09/11/07

Electronic Version

Gpsc Form 200-1 - Payphone Service Provider Registration September 2007 Page 5