NORCROSS SAVE Affidavit.pdf
PDF 577 KB Posted
- Attached to
- On-Call CIPP Relining Services (RFQ PW 26-05)
- Solicitation number
- PE-66780-NONST-2026-000000037
- Issued by
- Gwinnett County, Georgia
About this file
This is a compliance affidavit form issued by the City of Norcross, Georgia, in accordance 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, including occupational tax licenses, alcoholic beverage licenses, contract bids, and other applicable public benefit applications. Applicants must execute the affidavit under oath before a notary public and submit it with their associated application or bid packet. The form requires applicants to 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 under federal immigration law with a valid alien number. All applicants must also verify that they are at least 18 years of age and provide at least one secure and verifiable document as defined by Georgia law.
The affidavit is administered by the City of Norcross and includes notarization requirements and verification procedures that must be completed at the time of submission. Applicants who knowingly provide false, fictitious, or fraudulent statements face criminal penalties under O.C.G.A. 16-10-20. The form requires identification of the type of secure and verifiable document provided and must be signed by both the applicant and the notary public. This compliance document serves as a mandatory requirement for all public benefit applications and contracts administered by the City of Norcross, located at 65 Lawrenceville Street, Norcross, Georgia 30071.
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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 .