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Form # 4-D 1-1-12 Page 1 of 1 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. Signature of Exempt Private Employer Printed Name of Exempt 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: