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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 ten (10) or fewer employees and 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 provisions and deadlines established in O.C.G.A. § 36-60-6. I hereby declare under penalty of perjury that the foregoing is true and correct. Executed on 201__ in (city) (state). Printed Name of Exempt Private Employer Signature of Exempt Private Employer or Authorized Officer or Agent Printed Name and Title of Person Executing Affidavit SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF 201___. NOTARY PUBLIC My Commission Expires: