"Immigration Affidavit and Agreement Form" - Georgia (United States)

Immigration Affidavit and Agreement Form is a legal document that was released by the Georgia Department of Early Care and Learning - a government authority operating within Georgia (United States).

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Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Georgia Department of Early Care and Learning.

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Download "Immigration Affidavit and Agreement Form" - Georgia (United States)

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Bright from the Start: Georgia Department of Early Care and Learning
2 Martin Luther King Jr. Drive SE, 754 East Tower, Atlanta, Georgia 30334
IMMIGRATION AFFIDAVIT AND AGREEMENT
SFSP Sponsor/CACFP
Institution Name:
Agreement #:
Name of Public Employer:
Georgia Department of Early Care And Learning
By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91, stating
affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf
of the Georgia Department of Early Care and Learning has registered with, is authorized to use and uses 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. § 13-10-91.
Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the
contract period and the undersigned contractor will contract for the physical performance of services in satisfaction of
such contract only with subcontractors who present an affidavit to the contractor with the information required by
O.C.G.A. § 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date
of authorization are as follows:
Federal Work Authorization Company User Identification Number
Date of Authorization
(not user log in ID)
Name of Contractor (Principal and/or Program Contact)
I hereby declare under penalty of perjury that the foregoing is true and correct.
Printed Name (Principal and/or Program Contact)
Title
Signature (Principal and/or Program Contact)
Date Signed
Executed on ______, ___, 20__ in ____________________(city), ______(state).
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ______ DAY OF ______________, 20__
___________________________________________
NOTARY PUBLIC
[NOTARY SEAL]
My Commission Expires:______________________
Page 1
Bright from the Start: Georgia Department of Early Care and Learning
2 Martin Luther King Jr. Drive SE, 754 East Tower, Atlanta, Georgia 30334
IMMIGRATION AFFIDAVIT AND AGREEMENT
SFSP Sponsor/CACFP
Institution Name:
Agreement #:
Name of Public Employer:
Georgia Department of Early Care And Learning
By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91, stating
affirmatively that the individual, firm or corporation which is engaged in the physical performance of services on behalf
of the Georgia Department of Early Care and Learning has registered with, is authorized to use and uses 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. § 13-10-91.
Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the
contract period and the undersigned contractor will contract for the physical performance of services in satisfaction of
such contract only with subcontractors who present an affidavit to the contractor with the information required by
O.C.G.A. § 13-10-91(b). Contractor hereby attests that its federal work authorization user identification number and date
of authorization are as follows:
Federal Work Authorization Company User Identification Number
Date of Authorization
(not user log in ID)
Name of Contractor (Principal and/or Program Contact)
I hereby declare under penalty of perjury that the foregoing is true and correct.
Printed Name (Principal and/or Program Contact)
Title
Signature (Principal and/or Program Contact)
Date Signed
Executed on ______, ___, 20__ in ____________________(city), ______(state).
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ______ DAY OF ______________, 20__
___________________________________________
NOTARY PUBLIC
[NOTARY SEAL]
My Commission Expires:______________________
Page 1