Sub-Subcontractor Affidavit

Sub-subcontractor Affidavit under O.C.G.A. § 13-10-91(b)(4) By executing this affidavit, the undersigned sub-subcontractor verifies its compliance with O.C.G.A. § 13-10-91, stating affirmatively that the individual, firm or corporation which is engaged in the physical performance of services under a contract for (name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract):

___________________________________________________________________________________ and (name of contractor)___________________________________________________________________ on behalf of the Georgia Department of Defense 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 sub-subcontractor will continue to use the federal work authorization program throughout the contract period and the undersigned sub-subcontractor will contract for the physical performance of services in satisfaction of such contract only with sub-subcontractors who present an affidavit to the sub-subcontractor with the information required by O.C.G.A. § 13-10-91(b). The undersigned sub-subcontractor shall submit, at the time of such contract, this affidavit to (name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract):

__________________________________________________________. Additionally, the undersigned sub-subcontractor will forward notice of the receipt of any affidavit from a sub-subcontractor to (name of subcontractor or sub-subcontractor with whom such sub-subcontractor has privity of contract):

___________________________________________________________. Sub-subcontractor hereby attests that its federal work authorization user identification number and date of authorization are as follows:

_________________________________(E-Verify Company ID or Individual’s User ID) Federal Work Authorization User Identification Number

Date of Authorization

Legal Name of Sub-subcontractor

Legal Address of Sub-subcontractor

Name of Project

Georgia Department of Defense

DOD PO #

DOD PO Date Name of Public Employer

(For DOD use only)

(For DOD use only) I hereby declare under penalty of perjury that the foregoing is true and correct.

Executed on ______, ___, 201__ in _________________________(city), ______(state).

Signature of Authorized Officer or Agent

Printed Name and Title of Authorized Officer or Agent

SUBSCRIBED AND SWORN BEFORE ME

ON THIS THE ______ DAY OF ______________,201____.

_________________________________Notary Public

My Commission Expires:______________________________________________________