Citizenship Affidavit Form

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OFFICE OF COMMISSIONER OF INSURANCE

COMMISSIONER OF INSURANCE •INDUSTRIAL LOAN COMMISSIONER•SAFETY FIRE COMMISSIONER

Ralph T. Hudgens, Commissioner

2 Martin Luther King Jr., Dr.

West Tower, Atlanta, GA 30334

ENFORCEMENT

Illegal Immigration Reform And Enforcement Act

GID-276-EN

Notice

In accordance with O.C.G.A. §50-36-1, the Office of Insurance and Safety Fire Commissioner is required to verify

the lawful presence of all new and renewal applicants. Therefore, the following documents must be included

with [a] every new application submitted to this Office, regardless of the citizenship status of the applicant,

AND for [b] every renewal application submitted to this Office thereafter by non-citizen (alien) applicants:

1. A signed and notarized copy of the attached Citizenship Affidavit Form; and

2. A copy of the front AND back of one secure and verifiable identification document. (Attached is a list of

ALL secure and verifiable documents that this Office can accept in order to satisfy this requirement. We

cannot accept any documents that are not included in this list. These documents may be submitted to this

Office electronically.)

All applicants are required to submit LEGIBLE COPIES of these two (2) documents, as set forth in [a]

and/or [b] above, before an application can be processed. If applying on behalf of a business entity, then an

employee or officer of the business entity, who has authority, must complete and submit these documents as set

forth in [a] and/or [b] above. However, if there has been a change in the person who has authority to apply for

licensure on behalf of a licensed business entity, these documents must be completed and submitted by the

individual who currently has authority, regardless of the citizenship status of such individual.

In addition, if you (or, for a business entity, the employer or officer with authority) are not a United States citizen,

we are required by law to verify your immigration status through the Federal Systematic Alien Verification of

Entitlement (SAVE) program.

MAILING INSTRUCTIONS

Submit the two (2) required documents referenced above with your complete application to the email address (if

submitted digitally) OR to the mailing address (if submitted in paper form) specified in the application instructions.

HOW TO FILL OUT THE CITIZENSHIP AFFIDAVIT FORM

In the boxes at the top of the form, indicate in which of the three business types: INSURANCE (for this choice

specify Agent, Agency or Carrier), SAFETY FIRE, or INDUSTRIAL LOAN the affidavit pertains. Indicate the

business name on the line where the asterisk * is applicable to the choice. Also, provide the License #, NAIC# or

Employer ID# if known.

Spaces #1 - #3 – Applicant should put an X in the space that best describes the applicant’s citizenship status. Please

note that applicant should put an X in ONLY ONE of these spaces.

If you put an X in Space #2 (legal permanent resident) OR Space #3 (qualified alien or non-

•

immigrant), then applicant MUST write down the alien number that was issued by the

Department of Homeland Security or other federal immigration agency in the space provided.

Spaces #4 - #5 – Applicant should fill in the city and state in which this affidavit form is being notarized.

AN APPLICATION CANNOT BE PROCESSED IF THE

CITIZENSHIP AFFIDAVIT FORM IS NOT COMPLETELY FILLED OUT.

Affidavit

This office does not discriminate by race, color, national origin, sex, religion, age or disability in employment, programs or services. Disabled persons needing this

document in another format can contact the ADA Coordinator for this office at No. 2 Martin Luther King Jr., Dr., Suite 620, Atlanta, GA 30334 - Phone 404-656-2056.

Notice