United States A U

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 unexpired 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 rep- resentations 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 a 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. Unexpired Employment Authorization Document: REQUIRED OF ALL NON-CITIZENS. If I indicated other than United States citizenship in item #3 above, my Alien Registration Number issued by the Department of Homeland Security or other federal immigration agency 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-8/17) Side 1

Name: SSN:

SECURE AND VERIFIABLE DOCUMENTS UNDER O.C.G.A. & 50-36-2 Initials:

An unexpired United States passport or passport card An unexpired United States military identification card An unexpired driver’s license issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Islands, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer

An unexpired identification card issued by one of the United States, the District of Columbia, the commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Islands, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer An unexpired tribal identification card of a federally recognized Native American tribe, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer An unexpired United States Permanent Resident Card or Alien Registration Receipt Card An unexpired Employment Authorization Document that contains a photograph of the bearer An unexpired passport issued by a foreign government accompanied by a federal form specifying an individual’s lawful immigration status or other proof of lawful presence under federal immigration law An unexpired Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast Guard An unexpired Free and Secure Trade (FAST) card

An unexpired NEXUS card

An unexpired Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card An unexpired driver’s license issued by a Canadian government authority A Certificate of Citizenship issued by the United States Department of Citizenship and Immigration Services (USCIS)

A Certificate of Naturalization issued by the United States Department of Citizenship and Immigration Services (USCIS) (Form N-550 or Form N-570)

Certification of Birth issued by the United States Department of State (Form DS-1350) with an unexpired government-issued picture identification

Certification of Birth Abroad issued by the United States Department of State (Form FS-545) with an unexpired government-issued picture identification

Consular Report of Birth issued by the United States Department of State (Form FS-240) with an unexpired government-issued picture identification

An original or certified copy of a birth certificate issued by a state, county, municipal authority, or territory of the United States bearing an official seal with an unexpired government-issued picture identification DOL-1054A (R-8/17) Side 2

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