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Form Gj1000 - Application For Sales Tax License - City Of Grand Junction Financial Operations (Sales Tax), Affidavit Of Lawful Presence - 2013 Page 2

Business Name

City of Grand Junction

Affidavit of Lawful Presence

Required for Sole Proprietors applying for Sales Tax Licenses

I, _________________________________________________, swear or affirm under penalty of perjury under the

laws of the State of Colorado that (check one):

I am a United States Citizen, or

I am a legal Permanent Resident of the United States, or

I am otherwise lawfully present in the United States pursuant to Federal Law

I understand that this sworn statement is required by law because I have applied for a public benefit. I

understand that state law requires me to provide proof that I am lawfully present in the United States prior to

receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or

representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second

degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a

public benefit is fraudulently received.

Signature:

Date:

Per House Bill 2006S-1023, you must provide one of the following forms of identification:

Valid Colorado Driver's license

Colorado ID Card

United States Military Card or Military Dependent Card

United States Coast Guard Merchant Mariner Card

Native American Tribal Document

Other document allowed by the Colorado Department of Revenue Rules for lawful presence.

Form Gj1000 - Application For Sales Tax License - City Of Grand Junction Financial Operations (Sales Tax), Affidavit Of Lawful Presence - 2013 Page 2