GDOT Everify Form.pdf
PDF 127 KB Posted
- Solicitation number
- PE-66098-NONST-2026-000000096
- Issued by
- Fulton County, Georgia
About this file
This is a Contractor Affidavit form required by the Georgia Department of Transportation (GDOT) for compliance with O.C.G.A. 13-10-91. The form serves as a verification document that contractors engaged in the physical performance of services for GDOT have registered with and are authorized to use the federal E-Verify work authorization program, or any subsequent replacement program. Contractors must attest that they comply with applicable provisions and deadlines established under the statute. The affidavit requires contractors to provide their federal work authorization user identification number and date of authorization, along with the contractor's name, the authorized officer or agent's printed name and signature, title, and date signed. Contractors must execute this affidavit under penalty of perjury and have it notarized before a notary public.
Contractors are required to continue using the federal work authorization program throughout the entire contract period and must ensure that any subcontractors hired for the physical performance of services also present a completed affidavit containing the information required by O.C.G.A. 13-10-91(b). This affidavit form was last revised on November 1, 2015, and appears as page 71 of a 100-page document, indicating it is part of a larger solicitation or contract package for GDOT.
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Text version
Contractor’s Name:
Solicitation/Contract No./ Call No.
or Project Description:
CONTRACTOR AFFIDAVIT
By executing this affidavit, the undersigned contractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, entity or corporation which is engaged in the physical performance of services on behalf of the Georgia Department of Transportation 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 applicable provisions and deadlines established in O.C.G.A. § 13-10-91.
Furthermore, the undersigned contractor will continue to use the federal work authorization program throughout the contract period and the undersigned 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 information required by O.C.G.A. § 13-10- 91(b). Contractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:
Federal Work Authorization User Identification Number Date of Authorization (EEV/E-Verify Company Identification Number)
Name of Contractor
I hereby declare under penalty of perjury that the foregoing is true and correct
Printed Name (of Authorized Officer or Agent of Contractor) Title (of Authorized Officer or Agent of Contractor)
Signature (of Authorized Officer or Agent) Date Signed
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE
DAY OF , 20_
Notary Public
My Commission Expires:
[NOTARY SEAL]
Rev. 11/01/15 Page 71 of 100
| Contractors Name: |
| SolicitationContract No Call No or Project Description: |
| Federal Work Authorization User Identification Number: |
| Name of Contractor: |
| Printed Name of Authorized Officer or Agent of Contractor: |
| Date of Authorization: |
| Title of Authorized Officer or Agent of Contractor: |
| Date Signed: |
File details come from the government source that posted it. Updated .