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    Affidavit to be filed with the office of the Commissioner of insurance, Safety Fire and Industrial Loan Commissioner. Applicant hereby verifies that he or she is a qualified alien or non-immigrant under the federal immigration and nationality act. Applicant is also hereby verifying that he. Or she is J8 years of age or older and has provided at least one secure and verifiable document, as required by o. C. G. A. SS 5

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    Affidavit to be filed with the office of the Commissioner of insurance, Safety Fire and Industrial Loan Commissioner. Applicant hereby verifies that he or she is a qualified alien or non-immigrant under the federal immigration and nationality act. Applicant is also hereby verifying that he. Or she is J8 years of age or older and has provided at least one secure and verifiable document, as required by o. C. G. A. SS 5

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    Affidavit to be filed with the office of the Commissioner of insurance, Safety Fire and Industrial Loan Commissioner. Applicant hereby verifies that he or she is a qualified alien or non-immigrant under the federal immigration and nationality act. Applicant is also hereby verifying that he. Or she is J8 years of age or older and has provided at least one secure and verifiable document, as required by o. C. G. A. SS 5

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    of 1

    OFFICE OF COMMISSIONER OF INSURANCE

    COMMISSIONER OF INSURANCE INDUSTRIAL LOAN COMMISSIONER SAFETY FIRE COMMISSIONER

    Ralph T. Hudgens, Commissioner 2 Martin Luther King Jr., Dr., West Tower, Atlanta, GA 30334 www.ocl.ga.gov Illegal Immigration Reform And Enforcement Act Citizenship Affidavit Form ENFORCEMENT GID-276-EN AUG2G12 (replaces GID-23&F)

    If you know one o f the following identifiers, please enter it here: License # Employer I D #

    'Z'fS3 9*^13

    NAIC # O . C . G . A . 50-36-1(e)(2) Afndavit

    B y executing this affidavit under oath, as an applicant for a license, certificate, registration, permit, etc., as referenced in O . C . G . A . 50-36-1, from the Office o f Insurance, Safety Fire and Industrial Loan Commissioner, the undersigned applicant verifies one o f the following with respect to my application for a public benefit:

    [Check ONLY ONE ofthefoUowing:]


    1) 2) L J I am a United States citizen; O R 1 am a legal permanent resident o f the United States; O R My alien number issued by the Department o f Homeland Security or other federal immigration agency is: . 3) I I I am a qualified alien or non-immigrant under the Federal Immigration and Nationality A c t with an alien number issued by the Department o f Homeland Security or other federal immigration agency. M y alien number issued by the Department o f Homeland Security or other federal immigration agency is: . The undersigned applicant also hereby verifies that he or she is J8 years of age or older and has provided at least one secure and verifiable document, as required by O . C . G . A . 5 0 - 3 6 - l ( e ) ( l ) , with this affidavit. 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 o f a violation o f O . C . G . A . 16-10-20, and face criminal penalties as allowed by such criminal statute. Executed in Q. Signature (state) applicant

    SUBSCRIBED A N D SWORN B E F O R E ME..QN THIS T H E

    Printed Name o f Applicant 6f A p p l 'rinted

    i 3 ^ 4 y OF
    NOTA^'^UBLIC M y Commission Expires:

    2o:\

    I^Commiwion Bqpirae Oecembor 16.2013 SUBMIT ONLY THIS COMPLETED CITIZEN AFFIDA VITPAGE MTH THE REQUIRED
    Tliis office does not discnininate by nice, color, naUonai origin,
    SC.VL

    DOCUMENTATION
    Citizenship Affidavit

    reiigion, age or disabiJin,' in enipioynicni, programs or ser\ices. Disabled persons needing this - Phone 404-656-2056.

    documeni in another formal can contact the A D A Coordinator for this oflicc at No. 2 Mariin Luther King Jr., Dr., Suile 620, Atlanta, G.\4

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