Citizenship Affidavit Form Page 2

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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

Citizenship Affidavit Form

This affidavit is provided to satisfy the new or renewal requirements for an application in which one of the following types of business:

INSURANCE (Specify Entity Type):

SAFETY FIRE* (Specify Entity Type):

INDUSTRIAL

Individual

Business*

Carrier*

Engineering

Hazardous Materials

LOAN*

Manufactured Housing

Safety Engineering

* If the person providing the affidavit serves as “the designated responsible party” (ex.: owner/operator, partner, executive, etc…)

for one of these business types, please provide the name of the business:

If you know one of the following identifiers, please enter it here:

License #

NAIC #

Employer ID #

O.C.G.A. §50-36-1(e)(2) Affidavit

By executing this affidavit under oath, as an applicant for a license, certificate, registration,

permit, etc., as referenced in O.C.G.A. §50-36-1, from the Office of Insurance, Safety Fire and

Industrial Loan Commissioner, the undersigned applicant verifies one of the following with

respect to my application for a public benefit:

[Check ONLY ONE of the following:]

1) _________

I am a United States citizen; OR

2) _________

I am a legal permanent resident of the United States; OR

My alien number issued by the Department of Homeland Security or

other federal immigration agency is:___________________________.

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.

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

SUBSCRIBED AND SWORN

____________________________________

BEFORE ME ON THIS THE

___ DAY OF ___________, 20___

Printed Name of Applicant

_____________________________

NOTARY PUBLIC

My Commission Expires:

!! SUBMIT ONLY THIS COMPLETED CITIZENSHIP AFFIDAVIT PAGE WITH THE REQUIRED DOCUMENTATION !!

This office does not discriminate in employment, programs or services. Disabled persons can contact 404-656-2056 to obtain this document in another format.

Citizenship

Affidavit