NORCROSS SAVE Affidavit.pdf
PDF 577 KB Posted
- Attached to
- 2026 Road Resurfacing (ITB PW 26-08)
- Solicitation number
- PE-66780-NONST-2026-000000042
- Issued by
- Gwinnett County, Georgia
About this file
This file is a Security and Immigration Compliance Affidavit required by the City of Norcross, Georgia, pursuant to the Georgia Security and Immigration Compliance Act of 2006. The affidavit must be executed by all applicants seeking public benefits from the city, including occupational tax licenses, alcoholic beverage licenses, and other designated benefits. Applicants are required to complete the sworn affidavit before a notary public and submit it along with their application, renewal form, contract, bid packet, or related documentation. The form requires applicants to verify their lawful presence in the United States by selecting one of three categories: U.S. citizen, legal permanent resident, or qualified alien or non-immigrant with a valid alien number issued by the Department of Homeland Security or other federal immigration agency.
Applicants must also verify that they are at least 18 years of age and provide at least one secure and verifiable document as required by Georgia Code O.C.G.A. 50-36-1(f)(1), with a complete list of acceptable documents provided on the reverse side of the form. Applicants making false, fictitious, or fraudulent statements on the affidavit are subject to criminal penalties under O.C.G.A. 16-10-20. The affidavit requires completion and notarization by a notary public, including the notary's signature, commission expiration date, and location of execution. The City of Norcross is located at 65 Laurenceville Street, Norcross, Georgia 30071, with contact information provided as 770.448.2122 (phone) and 770.448.5945 (fax).
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .