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Private Employer Affidavit Pursuant to O.C.G.A. § 36-60-6(d) By executing this affidavit under oath, the undersigned private employer verifies one of the following with respect to its application for a business license, occupational tax certificate, or other document required to operate a business as referenced in O.C.G.A § 36-60-6(d). Section 1. On January 1st of the below-signed year, the individual, firm, or corporation employed more than ten employees. Section 2. The employer has registered with and utilizes the federal work authorization program in accordance with the applicable provisions and deadlines established in O.C.G.A. § 36-60-6. The undersigned private employer also attests that its federal work authorization user identification number and date of authorization are as follows: Name of Private Employer Federal Work Authorization User Identification Number Date of Authorization I hereby declare under penalty of perjury that the foregoing is true and correct. Executed on 201__ (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 201__. NOTARY PUBLIC My Commission Expires: To determine the number of employees for purposes of this affidavit, a business must count its total number of employees company-wide, regardless of the city, state, or country in which they are based, working at least 35 hours a week. Federal work authorization program is commonly known as E-Verify, therefore the Federal Work Authorization User Identification Number is the E-Verify Number.