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STATE OF BYB/Add. CWB Date
APPLICANT STATUS AFFIDAVIT
Comes now the undersigned, who, upon oath duly taken, states:
. My full name is and my Social Security Number is
- - . I present here my government-issued picture identiﬁcation in support of
this declaration of my name and identity. I am an applicant for a public beneﬁt, and I am making the representations
in this AFFIDAVIT to obtain that public beneﬁt.
2. I was born in [NAME OF COUNTRY] on / / , and I am 18 years
of age or older.
3. I declare [INITIAL ONE]: [ ] that I am a U.S. Citizen; OR [ ] that I am a legal permanent resident;
OR [ ] that I am qualiﬁed alien or non-immigrant under the federal Immigration and Nationality Act, Title 8 U.S.C.,
as amended, lawfully present in the United States.
4. Employment Authorization Document: REQUIRED OF ALL NON-CITIZENS. If I indicated other than United
States citizenship in item #3 above, my Alien Registration Number or other Number is:
Alien Registration # Card #
Citizenship Cert # Passport # (with)
Naturalization # I-94 Stamp # (or)
SEVIS ID # I-551 Stamp #
Expiration Date: I-94 #
and I present the original document here for your review and copying. Copy attached [ ]
5. Consent to Disclosure. I freely and voluntarily waive the conﬁdentiality provisions of the Immigration
Reform and Control Act of 1986 (IRCA) to permit the Department of Homeland Security (DHS) to provide the Georgia
Department of Labor information regarding my alien status for purposes of determining my eligibility for unemployment
insurance beneﬁts. I understand that IRCA precludes DHS from using, publishing or making available information
related to my application for adjustment to temporary residence except as provided by law (conﬁdentiality provision).
6. I understand that knowingly and willingly making a false, ﬁctitious, or fraudulent statement or representation in
this afﬁdavit is a violation of O.C.G.A. Code Section 16-10-20 and is subject to criminal prosecution under that and
other state and federal laws. I swear or afﬁrm that the citizenship and other information I have provided here is true
and correct to the best of my personal knowledge and belief.
Sworn to and subscribed before me
this day of , 20 .
Notary Public Claims Taker Signature
My Commission Expires:
Employee ID# (4 digits):
Note to Notary Public: Initial space on back of form
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