Form Crf-007 - Completion Of The Motor Fuel Distributor Application - 2013 Page 3
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CRF-007 (Rev. 9/13)
O.C.G.A. § 50-36-1(e)(2) Affidavit
By executing this affidavit under oath, as an applicant for a (n) ___________________________
[ type of public benefit], as referenced in O.C.G.A 50-36-1, from __________________________ [name
of government entity], the undersigned applicant verifies one of the following with respect to my
application for a public benefit:
1) _________ I am United States citizen.
2) _________ I am a legal permanent 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:
____________________.
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.
The secure and verifiable document provided with this affidavit can best be classified as:
____________________________________________________________________________________.
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 in __________________ (city), ___________________ (state).
_____________________________________
_____________________________________
Signature of Applicant
Printed Name of Applicant
SUBSCRIBED AND SWORN
BEFORE ME ON THIS THE
___ DAY OF _______, 20___
__________________
NOTARY PUBLIC
My Commission Expires:
This Affidavit must be signed by applicant. If applicant is a corporation, it must be signed by an officer of the corporation. A
stamped signature is not acceptable. You must attach a copy (front and back) of a secure and verifiable document as
defined in O.C.G.A. § 50-36-2. Examples of such documents include a valid Driver’s License or ID card issued by Georgia or
another State, a valid United States passport, or an original or certified copy of a birth certificate issued by a State, county,
municipal authority, or territory of the United States bearing an official seal. A complete list of secure and verifiable documents
may be found at https://etax.dor.ga.gov/ctr/2013_Secure_and_Verifiable_Document_Listing.pdf or on the Georgia Attorney
General’s website.
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