Exhibit 3 - Affidavit for Sole Proprietorship or Partnership.pdf
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- Attached to
- Automated Data Collection Van
- Solicitation number
- 300000117765804
- Issued by
- Missouri
About this file
This document is an affidavit form required by the Missouri Highways and Transportation Commission (MHTC), acting through the Missouri Department of Transportation (MoDOT), for sole proprietors or partners applying for public benefits including grants, contracts, and loans. The affidavit serves as sworn proof of lawful presence in the United States as mandated by Section 208.009, RSMo. A separate affidavit is required for each owner and general partner. The applicant must certify their status as either a United States citizen or an alien lawfully admitted for permanent residence, and must provide their name, relationship to the applying business, and applicable federal identification or Social Security number. The affidavit must be notarized and includes the notary's commission expiration date.
The document emphasizes the legal consequences of fraudulent statements, warning that obtaining public benefits through willfully false statements or fraudulent means constitutes stealing under Section 570.030, RSMo, with penalties ranging from Class C felony charges (up to 7 years imprisonment and $5,000 fine) for benefits valued between $500 and $25,000, to Class B felony charges (5 to 15 years imprisonment) for benefits exceeding $25,000. Applicants submitting this affidavit are eligible only for temporary public benefits until lawful presence is confirmed. MHTC/MoDOT is required to provide assistance in obtaining appropriate documentation to prove citizenship or lawful presence, and applicants must submit requests for such assistance in writing.
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Our mission is to provide a world-class transportation experience that delights our customers and promotes a prosperous Missouri.
EXHIBIT 3
APPLICANT AFFIDAVIT FOR SOLE-PROPRIETORSHIP OR PARTNERSHIP
(a separate affidavit is required for each owner and general partner)
STATE OF ______________________ )
) ss
COUNTY OF ____________________ )
On this _______ day of _____________________, 20_____, before me appeared
_________________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instruments, who being by me duly sworn, deposed as follows:
My name is __________________________________, and I am of sound mind, capable of making this affidavit, and personally certify the facts herein stated, as required by Section 208.009, RSMo, for failure to provide affirmative proof of lawful presence in the United States of America:
I am the _______________ of ______________________________, which is applying for a public benefit (grant, contract, and/or loan) administered/provided by the Missouri Highways and
Transportation Commission (MHTC), acting by and through the Missouri Department of Transportation
(MoDOT).
I am classified by the United States of America as: (check the applicable box) a United States citizen.
an alien lawfully admitted for permanent residence. I am aware that Missouri law provides that any person who obtains any public benefit by means of a willfully false statement or representation, or by willful concealment or failure to report any fact or event required to be reported, or by other fraudulent device, shall be guilty of the crime of stealing pursuant to
Section 570.030, RSMo, which is a Class C felony for stolen public benefits valued between
$500 and $25,000 (punishable by a term of imprisonment not to exceed 7 years and/or a fine not more than $5,000 – Sections 558.011 and 560.011, RSMo), and is a Class B felony for stolen public benefits valued at $25,000 or more (punishable by a term of imprisonment not less than 5 years and not to exceed 15 years – Section 558.011, RSMo).
I recognize that, upon proper submission of this sworn affidavit, I will only be eligible for temporary public benefits until such time as my lawful presence in the United States is determined, or as otherwise provided by Section 208.009, RSMo.
I understand that Missouri law requires MHTC/MoDOT to provide assistance in obtaining appropriate documentation to prove citizenship or lawful presence in the United States, and I agree to submit any requests for such assistance to MHTC/MoDOT in writing.
I acknowledge that I am signing this affidavit as a free act and deed and not under duress.
Affiant Signature Affiant’s Social Security Number or
Applicable Federal Identification Number
Subscribed and sworn to before me this ______ day of ________________, 20_____.
Notary Public
My commission expires:
owner or partner business name
File details come from the government source that posted it. Updated .