Form Center

2. SAVE Affidavit

   O.C.G.A. §50-36-1(e)(2) Affidavit 

4. 
   

   By executing this affidavit under oath, as an applicant for a(n)
   
   

5. Type of Business

   LLC, Corporation, Sole Proprietorship , etc.

7. as referenced in O.C.G.A §50-36-1, from the Greene County Board of Commissioners, the undersigned applicant verifies one of the following with respect to my application for a public benefit: 

9. Citizenship

   1. I am a United States citizen
   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.
11. My alien number issued by the Department of Homeland Security or other federal immigration agency is:

13. The undersigned applicant 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 O.C.G.A. §50-36-1(e)(1), with this affidavit.

15. The secure and verifiable document provided with this affidavit can best be classified as

    1. Driver's License
    2. United States Passport
    3. Military Identification Card
    4. United States Permanent Resident Card or Alien Registration Receipt Card
    5. Other:______________________________________________________

17. In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. §16- 10-20, and face criminal penalties allowed by such statute. 

    Executed on the______ day of ___________________, 20____ in,___________________________________

    
    

    ___________________________________________________________________
    Signature of Authorized Officer or Agent

    ___________________________________________________________________
    Printed Name of and Title of Authorized Officer or Agent 

    
    

    SUBSCRIBED AND SWORN BEFORE ME ON THIS THE _______ DAY OF _______________________, 20________

    
    

    ___________________________________________________________________
    Notary Public

    
    

    ___________________________________________________________________
    My Commission Expires

    
    

    
    

    AFFIX SEAL

Leave This Blank:


18. Print Only

* indicates a required field