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Form # 4-C 1-1-12 Page 1 of 1 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. Executed on , , 20__ in (city), (state). Signature of Authorized Officer or Agent Printed Name and Title of Authorized Officer or Agent SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF , 20 . NOTARY PUBLIC My Commission Expires: