Contractor Affidavit (29).pdf
PDF 105 KB Posted
- Attached to
- NFPA 1582 Firefighter Annual Medical Physicals
- Solicitation number
- PE-64800-NONST-2026-000000063
- Issued by
- Georgia
About this file
This is a Contractor Affidavit document required under O.C.G.A. § 13-10-91(b)(1) for a contract with Douglas County, Georgia related to NFPA 1582 Firefighter Annual Medical Physicals. The affidavit serves as a compliance verification document that contractors must execute to participate in the project. The document establishes the contractor's obligation to register with and utilize the federal E-Verify work authorization program throughout the entire contract period, including any renewals or extensions thereof.
The affidavit requires contractors to maintain continuous E-Verify enrollment and to notify Douglas County immediately if they cease using the program, with such cessation constituting a material breach of contract. Contractors must also ensure that all subcontractors submit compliant affidavits containing the information required by O.C.G.A. § 13-10-91(a), (b), and (c), and are responsible for submitting copies of affidavits, drivers' licenses, and identification cards to the public employer within five business days of receipt. The document must be executed under penalty of perjury and notarized, with the contractor providing their Federal Work Authorization User Identification Number and authorization date.
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Text version
Contractor Affidavit under O.C.G.A. § 13-I0-9l(b)(I)
The undersigned contractor ("Contractor") executes this Affidavit to comply with O.C.G.A § 13-10-91 related to any contract to which Contractor is a party that is subject to O.C.G.A. § 13-10-91 and hereby verifies its compliance with O.C.G.A. § 13-10-91, attesting as follows:
a) The Contractor has registered with, is authorized to use and uses the federal work authorization program commonly known as E-Verify, or any subsequent replacement program.
b) The Contractor will continue to use the federal work authorization program throughout the contract period, including any renewal or extension thereof.
c) The Contractor will notify the public employer in the event the Contractor ceases to utilize the federal work authorization program during the contract period, including renewals or extensions thereof.
d) The Contractor understands that ceasing to utilize the federal work authorization program constitutes a material breach of Contract.
e) The Contractor will contract for the 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(a), (b), and (c).
f) The Contractor acknowledges and agrees that this Affidavit shall be incorporated into any contract(s) subject to the provisions of O.C.G.A. § 13-10- 91 for the project listed below to which Contractor is a party after the date hereof without further action or consent by Contractor; and
g) Contractor acknowledges its responsibility to submit copies of any affidavits, drivers' licenses, and identification cards required pursuant to O.C.G.A. § 13-10-91 to the public employer within five business days of receipt.
Federal Work Authorization User Identification Number
Name of Contractor:
Date of Authorization
Name of Project
Douglas County, Georgia Name of Public Employer
I hereby declare under penalty of perjury that the foregoing is true and correct.
Executed on _______________, 20 ____ in _____________________(City) ____________(State).
Signature of Authorized Officer or Agent
Printed Name and Title of Authorized Officer or Agent
SUBSCRIBED AND SWORN BEFORE ME
ON THIS THE _____, DAY OF _____________ , 20 ____
NOTARY PUBLIC
My Commission Expires: _ _ _ _ _ _ _ _ _ _ _ _ lammons Cross-Out
Contractor Affidavit under O.C.G.A. § 13-I0-9l(b)(I)
File details come from the government source that posted it. Updated .