Form Mv-6 - Dealer, Distributor, Manufacturer, And Transporter Tag Application Page 2

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Customer ID Number

Registration Year

O.C.G.A.

50-36-1(e) (2) Affidavit

By executing this affidavit under oath, as an applicant for:

(Check all that apply.)

Motor Vehicle Dealer, Distributor, Manufacturer, or Transporter Tag

Motor Vehicle Temporary Site Permit

Out of State Recreational Vehicle Franchise Dealer Permit

as referenced in O.C.G.A

50-36-1, from the Georgia Department of Revenue, the undersigned applicant verifies one of

the following with respect to my application for a public benefit:

I am a United States citizen.

I am a legal permanent resident of the United States.

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:

You must submit a front and back copy of a Secure and Verifiable Document with this Affidavit. A complete list of Secure and Verifiable Documents may be found at

or on the Georgia Attorney General’s website. For more information please refer to

verification-faqs.