Immigration and Security Form.pdf
PDF 60 KB Posted
- Attached to
- School Campus FY2025 Paving Project
- Solicitation number
- PE-55185-NONST-2025-000000003
- Issued by
- Schley County, Georgia
About this file
This is a Georgia Department of Community Health (DCH) Immigration Compliance Affidavit form which includes sections for both contractors and subcontractors to verify compliance with Georgia Security and Immigration Compliance Act (O.C.G.A. § 13-10-91). The three-page document requires contractors to affirm their participation in federal work authorization programs operated by the U.S. Department of Homeland Security to verify information about newly hired employees under the Immigration Reform and Control Act of 1986.
The form requires contractors to list all subcontractors performing services under DCH contracts and obtain signed, notarized affidavits from each subcontractor within five days of their addition to the contract. Each party must provide their E-Verify company identification number, authorized officer signatures, and have their affidavits notarized. The form is specifically designed to ensure compliance with Georgia state immigration laws for companies doing business with the Department of Community Health.
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Other files
| File | Type | Posted |
|---|---|---|
| FY 2025 Paving Bid.pdf | ||
| Tax Compliance Form.pdf | ||
| SPD_SP012CertificateofNonCollusion (2).pdf | ||
| Paving Survey.pdf | ||
| SPD_SP042SupplierGeneralInformationWorksheet .pdf |
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Text version
GEORGIA DEPARTMENT OF COMMUNITY HEALTH (DCH)
DCH Immigration Compliance Affidavit Page 1 of 3
GEORGIA SECURITY AND IMMIGRATION COMPLIANCE ACT AFFIDAVIT
Contractor’s Name:
Contract No.:
CONTRACTOR AFFIDAVIT
By executing this affidavit, the undersigned Contractor verifies its compliance with O.C.G.A. § 13-10-
91, stating affirmatively that the Contractor identified above has registered with and is participating in a federal work authorization program*, in accordance with the applicability provisions and deadlines established in
O.C.G.A. § 13-10-91.
The undersigned further agrees that, should it employ or contract with any subcontractor(s) in connection with the performance of services pursuant to this contract with the Georgia Department of
Community Health (hereinafter “DCH”), Contractor will secure from such subcontractor(s) similar verification of compliance with O.C.G.A. § 13-10-91 on the attached Subcontractor Affidavit. Contractor further agrees to maintain records of such compliance and provide a copy of each such verification to DCH at the time the subcontractor(s) is retained to perform such service.
EEV / E-Verify
TM
Company Identification Number
BY: Signature of Authorized Officer or Agent Date of Contractor
Printed Name of Authorized Officer or Agent
Title of Authorized Officer or Agent
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
DCH Immigration Compliance Affidavit Page 2 of 3
ADDITIONAL INSTRUCTIONS TO CONTRACTOR: Please list below all subcontractors used to perform services under the DCH contract referenced above. In addition, you must attach a signed and notarized affidavit (third page of this form) from each of the subcontractors listed below. The contractor is responsible for providing a signed and notarized affidavit to DCH within five (5) days of the addition of any new subcontractor used to perform under the identified
DCH contract.
Subcontractors:
DCH Immigration Compliance Affidavit Page 3 of 3
Subcontractor’s
Name:
SUBCONTRACTOR AFFIDAVIT
By executing this affidavit, the undersigned Subcontractor verifies its compliance with O.C.G.A. § 13-
10-91, stating affirmatively that the Subcontractor which is engaged in the performance of services under a contract with the Contractor identified above on behalf of DCH has registered with and is participating in a federal work authorization program*, in accordance with the applicability provisions and deadlines established in
O.C.G.A. § 13-10-91.
EEV / E-Verify
TM
Company Identification Number
BY: Signature of Authorized Officer or Agent Date of Subcontractor
Printed Name of Authorized Officer or Agent
Title of Authorized Officer or Agent
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
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