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Revised 11/08/11 SPD-SP054 IMMIGRATION AND SECURITY FORM (GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT AFFIDAVIT) Contractor’s Name: County Solicitation/ Contract No.: CONTRACTOR AFFIDAVIT By executing this affidavit, the undersigned Contractor verifies its compliance with O.C.G.A. §13-10- 91, stating affirmatively that the Contractor identified above has registered with and is participating in a federal work authorization program*, in accordance with the applicability provisions and deadlines established in O.C.G.A. 13-10-91. The undersigned further agrees that, should it employ or contract with any subcontractor(s) in connection with the physical performance of services pursuant to this contract with the County, Contractor will secure from such subcontractor(s) similar verification of compliance with O.C.G.A. § 13-10-91 on the attached Subcontractor Affidavit. Contractor further agrees to maintain records of such compliance and provide a copy of each such verification to the County at the time the subcontractor(s) is retained to perform such service. EEV / E-VerifyTM Company Identification Number BY: Authorized Officer or Agent Date (Contractor Name) Title of Authorized Officer or Agent of Contractor Printed Name of Authorized Officer or Agent SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF 20___ [NOTARY SEAL] Notary Public My Commission Expires: *any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L. 99-603 ---PAGE BREAK--- Revised 11/08/11 SPD-SP054 IMMIGRATION AND SECURITY FORM (GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT AFFIDAVIT) Contractor’s Name: County Solicitation/ Contract No.: ADDITIONAL INSTRUCTIONS TO CONTRACTOR: Identify all subcontractors used to perform under the county contract. In addition, you must attach a signed and notarized affidavit (third page of this form) from each of the subcontractors listed below. The contractor is responsible for providing a signed and notarized affidavit to the County within five days of the addition of any new subcontractor used to perform under the identified County contract. Contractor’s Name: Subcontractors: ---PAGE BREAK--- Revised 11/08/11 SPD-SP054 IMMIGRATION AND SECURITY FORM (GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT AFFIDAVIT) Contractor’s Name: Subcontractor’s (Your) Name: County Solicitation/ Contract No.: SUBCONTRACTOR AFFIDAVIT By executing this affidavit, the undersigned Subcontractor verifies its compliance with O.C.G.A. §13- 10-91, stating affirmatively that the Subcontractor which is engaged in the physical performance of services under a contract with the Contractor identified above on behalf of the County identified above has registered with and is participating in a federal work authorization program*, in accordance with the applicability provisions and deadlines established in O.C.G.A. 13-10-91. EEV / E-VerifyTM Company Identification Number BY: Authorized Officer or Agent Date (Subcontractor Name) Title of Authorized Officer or Agent of Contractor Printed Name of Authorized Officer or Agent SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF 20___ [NOTARY SEAL] Notary Public My Commission Expires: *any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L. 99-603