CORRECTION Bryan Applicant Status Affidavitp
CORRECTION Bryan Applicant Status Affidavitp
CORRECTION Bryan Applicant Status Affidavitp
91F412E1-F170-486F-9F56-1EBECC908C4C
4. Unexpired Employment Authorization Document: REQUIRED OF ALL NON-CITIZENS. If I indicated other than
United States citizenship in item #3 above, my Alien Registration Number issued by the Department of Homeland
Security or other federal immigration agency or other number is:
Alien Registration # Card # 060700194
5. Consent to Disclosure. I freely and voluntarily waive the confidentiality provisions of the Immigration
Reform and Control Act of 1986 (IRCA) to permit the Department of Homeland Security (DHS) to provide the Georgia
Department of Labor information regarding my alien status for purposes of determining my eligibility for unemployment
insurance benefits. I understand that IRCA precludes DHS from using, publishing, or making available information
related to my application for adjustment to temporary residence except as provided by law (confidentiality provision).
6. I understand that knowingly and willingly making a false, fictitious, or fraudulent statement or representation in
this affidavit is a violation of O.C.G.A. Code Section 16-10-20 and is subject to criminal prosecution under that and
other state and federal laws. I swear or affirm that the citizenship and other information I have provided here is true
and correct to the best of my personal knowledge and belief.
Applicant Signature:
Initials:
An unexpired United States passport or passport card
An unexpired driver’s license issued by one of the United States, the District of Columbia, the Commonwealth
of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Islands,
American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient
identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to
enable the identification of the bearer
An unexpired identification card issued by one of the United States, the District of Columbia, the commonwealth of
Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Islands,
American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient
identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and
address to enable the identification of the bearer
An unexpired tribal identification card of a federally recognized Native American tribe, provided that it contains a
photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of
birth, gender, height, eye color, and address to enable the identification of the bearer
An unexpired United States Permanent Resident Card or Alien Registration Receipt Card
An unexpired passport issued by a foreign government accompanied by a federal form specifying an individual’s
lawful immigration status or other proof of lawful presence under federal immigration law
An unexpired Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast Guard
An unexpired Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card
A Certificate of Citizenship issued by the United States Department of Citizenship and Immigration
Services (USCIS)
A Certificate of Naturalization issued by the United States Department of Citizenship and Immigration
Services (USCIS) (Form N-550 or Form N-570)
Certification of Birth issued by the United States Department of State (Form DS-1350) with an unexpired
government-issued picture identification
Certification of Birth Abroad issued by the United States Department of State (Form FS-545) with an unexpired
government-issued picture identification
Consular Report of Birth issued by the United States Department of State (Form FS-240) with an unexpired
government-issued picture identification
An original or certified copy of a birth certificate issued by a state, county, municipal authority, or territory of the
United States bearing an official seal with an unexpired government-issued picture identification
DOL-1054A (R-3/20) Page 2 of 2