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1 SAVE AFFIDAVIT AFFIDAVIT VERIFYING STATUS FOR CITY PUBLIC BENEFIT 1(E)(2) - 36 - PURSUANT TO O.C.G.A. § 50 OFFICE OF REVENUE SUBMITTED TO DEPARTMENT OF FINANCE - [type of public benefit], as referenced in Occupational Tax Certificate By executing this affidavit under oath, as an applicant for an my O.C.G.A. § 50-36-1, from the City of Atlanta, Georgia, the undersigned applicant verifies one of the following with respect to application for a public benefit: 1) _______ I am a United States citizen. Please see link for acceptable forms of identification: http://law.ga.gov/immigration-reports 2) _______ I am a legal permanent resident of the United States. ** Please see link for acceptable forms of identification: http://law.ga.gov/immigration-reports 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.** Please see link for acceptable forms of identification: http://law.ga.gov/immigration-reports My alien number issued by the Department of Homeland Security or other federal immigration agency is: __________________________. nd The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one secure a verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit. The secure and verifiable document provided with this affidavit can best be classified as: __________________________________________________________________________________. In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitio us, 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 as allowed by such criminal statute. Executed in ________________ (City), ____________ (State). Signature of Applicant Date Printed Name of Applicant Name of Business Business License Acct No. SUBSCRIBED AND SWORN BEFORE ME ON THIS THE ____ DAY OF ____________, 20___. NOTARY PUBLIC /SEAL My Commission Expires: License Year 2018

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