E_Verify Affidavit (003).pdf

Illegal Immigration Reform and Enforcement Act of 2011 Affidavit

Project/RFQ No. and Name: ______________________________________________

STATE OF GEORGIA

COUNTY OF _______________________________

AFFIDAVIT

By executing this affidavit, the undersigned Contractor verifies:

1) Contractor is in compliance with the Illegal Immigration Reform and Enforcement Act of 2011 and specifically the provisions codified at O.C.G.A. §13-10-91;

2) Contractor is engaged in the physical performances of services on behalf of the Georgia Building Authority, and

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 in accordance with the provisions of O.C.G.A. § 13-10-91;

3) Contractor will continue to use the federal work authorization program throughout the contract period;

4) 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 same information required by O.C.G.A. § 13-10-91(b); and

5) If Contractor is not registered and participating in the E-Verify Program, or any subsequent replacement program, Contractor affirms that he has no employees, does not intend to hire employees for purposes of satisfying the terms of the contract, and has provided a copy of a state issued driver’s license or state issued identification card issued by a state within the United States that verifies lawful immigration status prior to issuing a driver’s license or identification card.

Federal Work Authorization/ E-VerifyTM Number: Authorization Date:

Signature of Authorized Officer or Agent Date

Title of Authorized Officer or Agent of Contractor Driver’s License # (Applicable only if Contractor is not Participating in E-Verify pursuant to _________________________________________ paragraph 5 above) Printed Name of Authorized Officer or Agent

Name of Contractor/Contracting Entity

SUBSCRIBED AND SWORN

BEFORE ME ON THIS THE

_____ DAY OF ______________________, 20__

________________________________________ [NOTARY SEAL]

Notary Public My Commission Expires: ___________________

*any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act of 1986 (IRCA), P.L. 99-603 (End of Form)

Project/RFQ No. and Name: ______________________________________________