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1-1-12 Dawson County, Georgia Board of Commissioners Private Employer Affidavit of Compliance Pursuant To O.C.G.A. § 36-60-6(d) By executing this affidavit, the undersigned private employer verifies its compliance with O.C.G.A. § 36-60-6, stating affirmatively that the individual, firm or corporation employs more than ten employees and has registered with and utilizes the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable provisions and deadlines established in O.C.G.A. § 13-10-90. Furthermore, the undersigned private employer hereby attests that its federal work authorization user identification number and date of authorization are as follows: Federal Work Authorization User Identification Number Date of Authorization Name of Private Employer I hereby declare under penalty of perjury that the foregoing is true and correct. Signature of Authorized Officer or Agent Printed Name and Title of Authorized Officer or Agent Subscribed and Sworn to me in the City of on this the day of , 20 . NOTARY PUBLIC My Commission Expires: See reverse side for Private Employer Exemption Affidavit ---PAGE BREAK--- 1-1-12 Dawson County, Georgia Board of Commissioners Private Employer Exemption Affidavit Pursuant To O.C.G.A. § 36-60-6(d) By executing this affidavit, the undersigned private employer verifies that it is exempt from compliance with O.C.G.A. § 36-60-6, stating affirmatively that the individual, firm or corporation employs fewer than eleven employees and therefore, is not required to register with and/or utilize the federal work authorization program commonly known as E-Verify, or any subsequent replacement program, in accordance with the applicable revisions and deadlines established in O.C.G.A. § 13-10-90. I hereby declare under penalty of perjury that the foregoing is true and correct. Printed Name of Exempt Private Employer Signature of Authorized Officer or Agent Printed Name and Title of Authorized Officer or Agent Subscribed and Sworn to me in the City of on this the day of , 20 . NOTARY PUBLIC My Commission Expires: