3-E Verify affadavit - fillable.pdf
PDF 102 KB Posted
- Attached to
- Tornado: Soldan ROOF & Tuckpointing
- Solicitation number
- RFP 094-2025
- Issued by
- St. Louis City, Missouri
About this file
This is a Federal Work Authorization Program Affidavit form for use in connection with a roofing and tuckpointing project at a St. Louis Public Schools (SLPS) facility in Missouri. The affidavit serves as a compliance document requiring vendors to confirm their enrollment in the E-Verify federal work authorization program and certify that they do not knowingly employ unauthorized aliens. The form requires completion by an authorized company representative over twenty-one years of age with firsthand knowledge of the company's employment practices, and must be notarized by a Missouri notary public. The affidavit applies to all employees working on the specified SLPS project.
This document is a mandatory compliance requirement rather than a pricing or contract terms document. Vendors bidding on the Tornado Soldan Roof & Tuckpointing project must complete and submit this notarized affidavit as part of their bid package to demonstrate adherence to federal work authorization requirements. The fillable PDF format allows vendors to electronically complete the form with their company information, authorized representative signature, and notarization details. No pricing, set-asides, contract terms, or project-specific deliverables are outlined in this affidavit; rather, it functions solely as a pre-qualification document to verify compliance with federal employment authorization standards.
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Text version
FEDERAL WORK AUTHORIZATION PROGRAM AFFIDAVIT
I, __________________________________________, being of legal age and having been duly sworn upon my oath, state the following facts are true:
1. I am more than twenty-one years of age; and have first-hand knowledge of the matters set forth herein.
2. I am employed by ____________________________________ (hereinafter “Company”) and have authority to issue this affidavit on its behalf.
3. Company is enrolled in and participating in the United States E-Verify (formerly known as “Basic Pilot”) federal work authorization program with respect to Company’s employees working in connection with the services Company is providing to, or will provide to, the district, to the extent allowed by E-Verify.
4. Company does not knowingly employ any person who is an unauthorized alien in connection with the services Company is providing to, or will provide to, the district.
FURTHER AFFIANT SAYETH NOT.
By: _________________________________________________ (individual signature)
For: ________________________________________________ (company name)
Title: _______________________________________________
STATE OF MISSOURI)
) ss.
COUNTY OF __________________________)
On this _______ day of ______________, 20____, before me, _______________________, a Notary Public in and for such County and State, personally appeared _______________________________________ of
___________________________________________, known to me to be the person who executed the affidavit on behalf of said ________________________ and acknowledged to me that he or she executed the same for the purposes therein stated. Subscribed and affirmed before me this _______ day of
_________________, 20______.
Notary Public My commission expires on: _________________________
| I: |
| 2 I am employed by: |
| By: |
| For: |
| Title: |
| COUNTY OF: |
| On this: |
| day of: |
| 20: |
| before me: |
| and for such County and State personally appeared: |
| known to me to be the person who executed the: |
| affidavit on behalf of said: |
| same for the purposes therein stated Subscribed and affirmed before me this 1: |
| same for the purposes therein stated Subscribed and affirmed before me this 2: |
| 20_2: |
| Notary Public: |
| My commission expires on: |
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