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GORDON COUNTY BOARD OF COMMISSIONERS AFFIDAVIT VERIFYING STATUS FOR COUNTY BENEFIT APPLICATION By executing this affidavit under oath, as an applicant for the Gordon County Board of Commissioners, Georgia Business License or Occupation Tax certificate, Alcohol License, or other public benefit as referenced in O.C.G.A. Section 50-‐36-‐1, I am stating the following with respect to my application for the Gordon County Board of Commissioners, Georgia Business License or Occupation Tax certificate, Alcohol License, or other public benefit (circle one) for (Name of natural person applying on behalf of individual, business, corporation, partnership, or other private entity) 1) I am a United States citizen OR 2) I am a legal permanent resident 18 years of age or older or I am an otherwise qualified alien or non-‐immigrant under the Federal Immigration and Nationality Act 18 years or age or older and lawfully present in the United States.* In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of Code Section 16-‐10-‐20 of the Official Code of Georgia. Signature of Applicant: Date: Printed Name: Alien Registration number for non-‐citizens SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ____DAY OF 20___ Notary Public My Commission *Note: O.C.G.A. 50-‐36-‐1 requires that aliens under the federal Immigration and Nationality Act, Title 8 U.S.C., as amended, provide their alien registration number. Because legal permanent residents are included in the federal definition of “alien” , legal permanent residents must also provide their alien registration number. Qualified aliens that do not have an alien registration number may supply another identifying number below: