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Puerto Rico Applicant Status Affidavit Form

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Puerto Rico Applicant Status Affidavit Form
Puerto Rico Applicant Status Affidavit Form
STATE OF BYB/Add. CWB Date
COUNTY OF
APPLICANT STATUS AFFIDAVIT
[O.C.G.A. 50-36-1]
Comes now the undersigned, who, upon oath duly taken, states:
1
. 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 .
Applicant Signature:
Notary Public Claims Taker Signature
My Commission Expires:
Employee ID# (4 digits):
Note to Notary Public: Initial space on back of form
to indicate document(s) provided.
For Central Office Only:
Cert # Emp. Elig. Date
Secondary Verification q Yes q No
Remarks
DOL-1054A (R-8/13) Side 1
Puerto Rico Applicant Status Affidavit Form
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