NORCROSS SAVE Affidavit.pdf
PDF 577 KB Posted
- Attached to
- Mobile Data Analytics Services (RFP 26-07)
- Solicitation number
- PE-66780-NONST-2026-000000044
- Issued by
- Gwinnett County, Georgia
About this file
This is a SAVE Public Benefit Affidavit form issued by the City of Norcross, Georgia, in compliance with the Georgia Security and Immigration Compliance Act of 2006 (O.C.G.A. 50-36-1). The affidavit is required for all applicants seeking public benefits from the City of Norcross, including occupational tax licenses, alcoholic beverage licenses, contract bids, and other applicable public benefits. Applicants must verify their lawful presence in the United States by selecting one of three options: U.S. citizenship, legal permanent resident status, or qualified alien/non-immigrant status with a Department of Homeland Security alien number. The form must be executed before a notary public and submitted with the associated application, renewal form, contract, bid packet, or other related documentation. Applicants must also verify they are 18 years of age or older and provide at least one secure and verifiable document as specified under Georgia law.
The affidavit contains no pricing terms, contract amounts, or funding information, as it serves as a compliance verification document rather than a procurement instrument. False statements made in the affidavit constitute a violation of O.C.G.A. 16-10-20 and subject the applicant to criminal penalties. The notary public must complete the attestation section by certifying the date, location, and validity of the applicant's oath. All applicants must return the completed and notarized affidavit to the City of Norcross along with their application materials and proof of secure and verifiable documentation.
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Text version
Instructions: As required by Georgia Security and Immigration Compliance Act of 2006, as amended, every agency administering or providing Public Benefits is responsible for requiring that applicants for public benefits execute a sworn affidavit verifying the applicant’s lawful presence in the United States (Ga. Code 50-36- 1(f)(2). The applicant shall execute this affidavit in front of a Notary and return it to the city along with the associated application, renewal form, contract, bid packet, or other applicable document.
By executing this affidavit under oath, as an applicant for (Occupational Tax license or Alcoholic Beverage license or any other Public benefit) as referenced in O.C.G.A. § 50-36-1, from the City of Norcross, the undersigned applicant verifies one of the following with respect to my application for public benefit.
(Please check one)
1) I am a United States citizen. (REQUIRES VERIFICATION AT SUBMISSION)
2) I am a legal permanent resident of the United States.
3) I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued by the Department of Homeland Security or other federal immigration agency.
My alien number issued by the Department of Homeland Security or other federal immigration agency is: _.
The undersigned applicant has also hereby verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, as required by Georgia Law O.C.G.A § 50-36-1(f) (1) A complete list of secure and verifiable documents on back of this form.
REQUIRES VERIFICATION AT SUBMISSION – Which type of secure and verifiable document was provided with this affidavit? .
In making the above representation under oath, I understand that any person who knowingly and willfully who makes a false, fictitious, or fraudulent statement or representation in this affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal statute.
MUST BE COMPLETED BY NOTARY
I, (representative for) (Printed NAME of individual and natural person) (Name of BUSINESS, corporation, partnership, etc.)
Signature of Applicant Date
SUBSCRIBED AND SWORN BEFORE ME ON THIS THE DAY OF ,20
Executed in (City), (State)
NOTARY PUBLIC Signature My Commission Expires
65 Lawrenceville St. Norcross, GA 30071 [P] 770.448.2122 [F] 770.448.5945 www. norcrossga.net
SAVE Public Benefit Affidavit
O.C.G.A. § 50-36-1
File details come from the government source that posted it. Updated .