Affidavit Verifying Status Of Benefit Applicant printable pdf download

_____________________________________

Taxpayer Name

________________________________________

Mailing Address

________________________________________

RDS Account Number: _____________________

City, State, Zip

Affidavit Verifying Status of Benefit Applicant

**REQUIRED**

Pursuant to the Georgia Security and Immigration Compliance Act (O.C.G.A 50-36-1), effective July 1, 2007, every agency in Fulton

County providing public benefits through any local program is responsible for determining the immigration status of citizen applicants

for said benefits.

By executing this affidavit under oath, as an applicant for benefits, I am stating the following with respect to my application for benefits

from Fulton County Government:

Select one of the below.

_____________________ I am a United States citizen 18 years of age or older;

_____________________ I am a legal permanent resident 18 years of age or older;

_____________________ I am a qualified alien or non-immigrant under the Federal Immigration and

Nationality Act, Title 8 U.S.C., as amended, 18 years of age or older and lawfully present in the United

States. My alien number issued by the U.S. Department of Homeland Security or other federal

immigration agency is ________________________________________.

The undersigned applicant also hereby verifies that he or she 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:

_______________________________________________________________________

(Please enclose legible copy of document with 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.

Executed in _____________________________(city), ______________________(state).

_________________________________________

_______________________________

Signature of Applicant

Date

_________________________________________

Printed Name

Subscribed to and sworn before me on this the

___________ Day of _________________20_____.

__________________________________________

Notary Public

My Commission Expires:

__________________________________________

**FORM REQUIRED*** This form must be completed and returned with a copy of your secure and

verifiable document, your Fulton County Occupational Tax Renewal and payment. Failure to return

the completed Affidavit with your renewal and payment will delay the issuance of your occupational

certificate.

Affidavit Verifying Status Of Benefit Applicant

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