Occupational Tax Certificate Return Form - City Of Dalton

AFFIDAVIT VERIFYING STATUS FOR CITY

PRIVATE EMPLOYER AFFIDAVIT

PUBLIC BENEFIT APPLICATION

PURSUANT TO O.C.G.A § 36-60-6(d)

CITY OF DALTON, GEORGIA

MUST BE NOTARIZED

By Executing This Affidavit Under Oath, As An Applicant For A

CHECK ONLY ONE:

City Of Dalton, Georgia Business License Or Occupation Tax

Certificate, Alcohol License, Taxi Permit Or Other Public Benefit

By executing this affidavit, the undersigned private

As Referenced In O.C.G.A. Section 50-36-1, I Am Stating The

employer verifies its compliance with O.C.G.A. § 36-60-6,

Following With Respect To My Application For A City Of Dalton,

stating affirmatively that the individual, firm or corporation has

Business License Or Georgia Occupational Tax Certificate, Alcohol

registered with and utilizes the federal work authorization

License, Taxi Permit Or Other Public Benefit For:

program commonly known as E-Verify, or any subsequent

replacement program, in accordance with the applicable

___________________________________.

provisions and deadlines established in O.C.G.A. § 36-60-6.

[Name Of Natural Person Applying On Behalf Of Individual,

Furthermore, the undersigned private employer hereby attests

Business, Corporation, Partnership, Or Other Private Entity]

that its federal work authorization user identification number and

date of authorization are as follows:

1) _____ I Am A United States Citizen

_________________________________

Federal Work Authorization User Identification Number

(E-Verify Company ID Number)

2) _____ I Am A Legal Permanent Resident 18 Years Of Age Or

Older Or I Am An Otherwise Qualified Alien Or Non-Immigrant

____________________

Under The Federal Immigration And Nationality Act 18 Years Of

Date of Authorization

Age Or Older And Lawfully Present In The United States.*

_________________________________

2a) Date of Birth: _________________________

Signature of Authorized Officer or Agent

2b) _____________________________________

____________________________________________

*Alien Registration Number For Non-Citizens

Printed Name and Title of Authorized Officer or Agent

_______________________________________________________

In Making The Above Representation Under Oath, I Understand

That Any Person Who Knowingly And Willfully Makes A False,

By executing this affidavit, the undersigned private

Fictitious, Or Fraudulent Statement Or Representation In An

employer verifies that it is exempt from compliance with

Affidavit Shall Be Guilty Of A Violation Of Code Section 16-10-20

O.C.G.A. § 36-60-6, stating affirmatively that the individual,

Of The Official Code Of Georgia.

firm, or corporation employs ten (10) or fewer employees and

is not required to register with and/or utilize the federal

The secure and verifiable document provided with this affidavit can

work authorization program commonly known as E-Verify,

best be classified as:

or any subsequent replacement program, in accordance with the

__________________________________________________

applicable provisions and deadlines established in O.C.G.A. §

** (Please submit a copy of the secure and verifiable document

36-60-6.

along with the application. E.g., Driver’s License)

_________________________________

Signature of Exempt Private Employer

__________________________________

Signature Of Applicant

_________________________________

Printed Name of Exempt Private Employer

__________________________________

Printed Name

__________________________________________________________

I hereby declare under penalty of perjury that the foregoing is true and

SUBSCRIBED AND SWORN BEFORE ME

correct. Executed on _____________, ___, 201___

ON THIS THE _____ DAY OF ___________, 20____

in__________________________(city), ______(state).

__________________________________

SUBSCRIBED AND SWORN BEFORE ME

Notary Public

ON THIS THE ______ DAY OF ______________, 201__.

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

NOTARY PUBLIC

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

My Commission Expires:

number. Qualified aliens that do not have an alien registration

_________________________________

number may supply another identifying number below:

_______________________________

Occupational Tax Certificate Return Form - City Of Dalton - 2016 Page 2

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