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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 E-Verify 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 DAY OF , 20 NOTARY MY COMMISSION EXPIRES: Form #4-B 7-11-24