HomeMy Public PortalAboutAffidavit Verifying Status.pdfAffidavit Verifying Status
for City Public Benefit Application
By executing this affidavit under oath, as an applicant for a City of Tybee Island, Georgia, Business License or
Occupation Tax Certificate, Alcohol License, Taxi Permit, Contract, 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 of a City of Tybee Island:
• Business License or Occupational Tax Certificate,
• Alcohol License,
(circle all that apply)
• Taxi Permit,
• Contract 11
• Other public benefit C ► �I - 1�� r1CiOf
for j/ G ,e_T(4 eD%11100�7 earn (printed name of natural person applying
on behalf of individual, business, corporation, partnership, or othe 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 of 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 Expires:
Note: U. C. G.A. § 5O -36-1(e)(2) 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 identifinng number below: