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Navigating the legal requirements of acquiring public benefits in the United States can be complex, especially when it comes to proving eligibility. One key document in this process is the Applicant Status Affidavit. This form, coded under O.C.G.A. 50-36-1, serves as a critical declaration by applicants seeking public benefits, where they must affirm their identity, legal status, and eligibility under the oversight of various compliance and legal frameworks. The affidavit requires the applicant to disclose their full name, social security number, and provide unexpired government-issued identification to substantiate the claims made within the document. Furthermore, applicants must state their birth country, assert their citizenship or legal presence in the U.S., and, if applicable, share their alien registration number or other identifiers that confirm their status as non-citizens. This form also includes a consent provision, allowing for the release of information to the Department of Homeland Security for verification purposes, emphasizing the importance of transparency and the legal ramifications of fraudulent claims. With the inclusion of a section on secure and verifiable documents, the form outlines acceptable forms of identification, ensuring that applicants are clearly guided on the requirements for proving eligibility for the intended public benefit.

Form Example

STATE OF

 

BYB/Add. CWB Date

COUNTY OF

 

 

 

 

 

 

 

APPLICANT STATUS AFFIDAVIT

 

 

 

 

 

 

[O.C.G.A. 50-36-1]

Comes now the undersigned, who, upon oath duly taken, states:

1. My full name is

 

 

 

 

and my Social Security Number is

 

-

 

 

-

 

. I provide my unexpired government-issued picture identification

in support of this declaration of my name and identity. I am an applicant for a public benefit, and I am making the rep- resentations in this AFFIDAVIT to obtain that public benefit.

2.

I was born in [NAME OF COUNTRY]

on

/

/

 

, and I am 18 years

of age or older.

 

 

 

 

 

 

 

 

 

 

 

 

3.

I declare [INITIAL ONE]: [

 

] that I am a U.S. Citizen; OR [

 

 

 

] that I am a legal permanent resident;

OR [ ] that I am a qualified alien or non-immigrant under the federal Immigration and Nationality Act, Title 8 U.S.C.,

as amended, lawfully present in the United States.

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 #

 

 

 

Citizenship Cert #

 

 

Passport #

 

(with)

Naturalization #

 

 

I-94

Stamp #

 

 

(or)

SEVIS ID #

 

 

I-551 Stamp #

 

 

 

Expiration Date:

 

 

I-94

#

 

 

 

 

 

 

 

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:

Claims Taker Signature

Employee ID# (4 digits):

For Central Office Only:

Cert #

 

 

Emp. Elig. Date

 

 

Secondary Verification

q Yes q No

Remarks

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOL-1054A (R-3/20) Page 1of 2

Name:

 

SSN:

SECURE AND VERIFIABLE DOCUMENTS UNDER O.C.G.A. & 50-36-2

Initials:

An unexpired United States passport or passport card

An unexpired United States military identification 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 Employment Authorization Document that contains a photograph of the bearer

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 Free and Secure Trade (FAST) card

An unexpired NEXUS card

An unexpired Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card

An unexpired driver’s license issued by a Canadian government authority

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

Document Features

Fact Name Fact Detail
Governing Law O.C.G.A. 50-36-1
Purpose To declare eligibility for a public benefit
Requirement for Submission Applicants must be 18 years of age or older
Citizenship Declaration Applicants must declare if they are a U.S. Citizen, a legal permanent resident, or a qualified alien/non-immigrant
Documentation for Non-Citizens Non-citizens must provide an unexpired Employment Authorization Document
Consent to Disclosure Applicants waive confidentiality for the purpose of determining eligibility for unemployment benefits
False Statements Making a false statement is a violation subject to prosecution
Secure and Verifiable Documents Includes U.S. passport, military ID, driver’s license, etc., for identity verification
Signature Requirement Applicant and Claims Taker must both sign the affidavit

How to Use Applicant Status Affidavit

After you've gathered your personal identification and relevant documents, completing the Applicant Status Affidavit form is your next step toward accessing certain public benefits. This form verifies your status and eligibility under the law, and it's crucial that you provide accurate and up-to-date information. Follow these detailed steps to ensure your affidavit is correctly filled out, which will streamline the process and avoid potential delays.

  1. Start by clearly writing the date and specifying the county and state at the top of the form where indicated.
  2. Enter your full legal name and Social Security Number (SSN) in the space provided. Ensure the name matches the one on your government-issued ID.
  3. Attach or provide evidence of an unexpired government-issued picture identification, such as a driver's license or passport. This ID is necessary to prove your identity and support the declaration made in the affidavit.
  4. Highlight your birth country and date of birth. Verify that you are 18 years of age or older, as this is a requirement to make the affidavit.
  5. Check the appropriate box to indicate your status: U.S. Citizen, legal permanent resident, or a qualified alien or non-immigrant under federal immigration laws. Your selection here determines what additional information you need to provide.
  6. If you are not a U.S. citizen, you must provide your Alien Registration Number or other relevant identification numbers such as Card #, Citizenship Cert #, Passport #, Naturalization #, I-94 Stamp #, SEVIS ID #, or I-551 Stamp #, including the expiration date where applicable.
  7. Consent to the disclosure of your status by signing the waiver that allows the Department of Homeland Security (DHS) to share your alien status with the Georgia Department of Labor. This step is essential for verifying your eligibility for the public benefit.
  8. Acknowledge your understanding that providing false information is a criminal offense by reading the statement regarding the violation of O.C.G.A. Code Section 16-10-20.
  9. Sign the affidavit to affirm that all the information you've provided is true and correct to the best of your knowledge and belief. Your signature is a crucial step in the completion of this affidavit.
  10. Have the form processed and signed by the Claims Taker, who will fill out their part, including the Employee ID# and any remarks for the Central Office.

Upon successfully filling out and submitting the Applicant Status Affidavit form, your information will be reviewed for eligibility for the specified public benefit. The review process considers the accuracy of your information and the validity of your documents. It's important to wait for official communication regarding the next steps or any additional requirements needed to finalize your application for the benefit.

Listed Questions and Answers

What is an Applicant Status Affidavit?

An Applicant Status Affidit is a legal document where an individual declares their citizenship or immigration status under oath to obtain a public benefit. This affidavit includes the full name and Social Security Number of the applicant, alongside a declaration of citizenship or lawful presence in the United States as per federal Immigration and Nationality Act guidelines.

Who needs to fill out an Applicant Status Affidavit?

Applicants for public benefits in the state of Georgia who are 18 years of age or older need to fill out this affidavit. It is a requirement to officially record and verify the applicant's eligibility for the benefits they are applying for, based on their residency or citizenship status.

What documents are required to support the affidavit?

To support the affidavit, applicants need to provide unexpired, government-issued picture identification. Some of the acceptable documents include:

  • An unexpired United States passport or passport card
  • An unexpired driver's license or identification card from any of the United States or its territories
  • An unexpired tribal identification card from a federally recognized Native American tribe
  • An unexpired Permanent Resident Card or Alien Registration Receipt Card
  • Various other documents listed in the affidavit that prove lawful presence under federal immigration law

How does an individual declare their citizenship status on the affidavit?

On the affidavit, the individual must initial next to the statement that applies to their status: U.S. Citizen, legal permanent resident, or qualified alien or non-immigrant under the federal Immigration and Nationality Act. This declaration must be supported by appropriate, official documentation.

What happens if someone cannot provide a Social Security Number?

Applicants must provide a Social Security Number as part of the affidavit process. If someone cannot provide this, they may need to seek legal guidance or contact the agency requesting the affidavit for alternative options. The form is designed to verify eligibility for public benefits which often requires a Social Security Number.

Is there a penalty for providing false information on the affidavit?

Yes, knowingly and willingly making a false, fictitious, or fraudulent statement or representation on this affidavit is a violation of O.C.G.A. Code Section 16-10-20 and is subject to criminal prosecution under state and federal laws. It is crucial that all information provided on the affidavit is true and correct to the best of the applicant's knowledge.

The Consent to Disclosure section waives the confidentiality provisions of the Immigration Reform and Control Act of 1986. This allows the Department of Homeland Security to share information regarding the applicant's alien status with the Georgia Department of Labor, for the purpose of determining eligibility for unemployment insurance benefits.

What happens after submitting the affidavit?

After submission, the affidavit and accompanying documents are reviewed by the relevant state department or agency to verify the applicant's eligibility for the public benefit they are applying for. This may include secondary verification of the information provided.

Can non-U.S. citizens also apply for public benefits using this affidavit?

Yes, non-U.S. citizens can apply for public benefits, provided they are legal permanent residents or qualified aliens/non-immigrants lawfully present in the United States. They must present documentation, such as an unexpired Employment Authorization Document, as part of the affidavit process.

How long does the process take?

The processing time can vary depending on the department or agency reviewing the affidavit and the need for secondary verification of documentation. Applicants are advised to submit their affidavits and supporting documents well in advance of when they need the public benefit to account for processing times.

Common mistakes

Filling out the Applicant Status Affidavit form is a crucial step in applying for public benefits, but it can be tricky. People often make mistakes on this form which can delay or even derail their applications. Here are four common mistakes to watch out for:

  1. Providing Incorrect Personal Information: One of the most crucial parts of this form is your personal information. People sometimes enter their name or Social Security Number incorrectly. Double-check this information to ensure it matches exactly with your official documents.

  2. Forgetting to Initial the Declaration of Status: In section 3, you need to declare your citizenship or immigration status by initialing the appropriate box. It's a simple step but forgetting to do this can result in the application being incomplete.

  3. Leaving the Alien Registration Number Blank: Non-citizens must provide their Alien Registration Number or other relevant numbers in section 4. This mistake is easy to make if you're not clear on your status or don't have the documents handy. Make sure you have all your immigration documents before you start filling out the form.

  4. Failure to Provide or Update the Expiry Date of Documents: All documents proving your status need to be current and unexpired. People sometimes forget to check if their documents are still valid or forget to include the expiration date on the form. This oversight can lead to delays in processing.

Besides these mistakes, always sign the form and ensure that all the information provided is true and correct to the best of your knowledge. Misrepresentations or false statements can have legal consequences. Paying close attention to these details can help make the process smoother and faster.

Documents used along the form

When submitting an Applicant Status Affidavit, there are other forms and documents often needed to complete an application process for a public benefit. Understanding what these documents are and their purposes can simplify the process and ensure that applicants provide all the necessary information required by the governing bodies or institutions. Below is a list of commonly required documents that accompany the Applicant Status Affidavit.

  • Proof of Identity and Age: An unexpired government-issued identification card, such as a driver’s license or passport, is essential. It serves to confirm the applicant's identity and that they meet the minimum age requirement.
  • Birth Certificate: An original or certified copy of a birth certificate verifies the applicant's birthplace and date of birth. This document is crucial for establishing nationality and age.
  • Social Security Card: This card is necessary for verifying the applicant’s Social Security number, an important part of confirming eligibility for various benefits and for employment verification.
  • Proof of Residence: documents like a recent utility bill, lease agreement, or mortgage statement confirms the applicant's current address. This is important for state-specific benefits and for establishing residency within a jurisdiction.
  • Employment Authorization Document (EAD): For non-citizens, an EAD is required to prove that the applicant is allowed to work in the United States legally. It's pivotal for those seeking employment-related public benefits.
  • Citizenship or Naturalization Documents: For those not born in the United States but claiming U.S. citizenship, presenting a Certificate of Naturalization or Citizenship is necessary. These documents serve as proof of legal citizenship status.

Gathering these additional documents before filing an application can help ensure a smoother process. Each document serves its unique purpose, from establishing legal identity and work eligibility to verifying age, residence, and citizenship status. Being prepared with the right documentation can expedite the application process for public benefits, making it less daunting and more efficient.

Similar forms

The Applicant Status Affidavit form is similar to several other documents in terms of its function and the kind of information it collects. These documents, while varied in their specific use cases, share commonalities in verifying identity, legal status, and eligibility for benefits or permissions under U.S. law.

Employment Authorization Document (EAD): Much like the Applicant Status Affidavit, the EAD is essential for non-citizens to prove their eligibility to work in the United States legally. Both documents require detailed personal identification, including an alien registration number for those who are not U.S. citizens. Moreover, both involve a process verifying that the individual holds a lawful status that permits them to obtain certain benefits—in the case of the EAD, the benefit is employment, whereas, for the affidavit, it might range across various public benefits.

Driver’s License or State ID: State-issued identification such as a driver’s license or non-driver ID card closely resembles the Applicant Status Affidavit because they both serve as secure and verifiable documents under O.C.G.A. & 50-36-2. These forms of identification require proof of identity, legal status, and residency, similar to the affidavit form. For instance, an unexpired driver’s license is a commonly accepted form of identification that bears the holder's photograph and provides significant personal information, paralleling the affidavit's requirements. Both are instrumental in accessing services and benefits, thus playing a critical role in the verification process.

Passport or Passport Card: The parallels between a passport and the Applicant Status Affidavit are evident in their use as proof of identity and citizenship. Just as a passport can serve as a primary form of identification for international travel, showcasing a person’s nationality and personal details, the affidavit confirms an individual's legal status and eligibility for public benefits within the United States. Both documents demand the inclusion of a photograph for identification and require thorough validation processes.

Permanent Resident Card (Green Card): This document and the Applicant Status Affidavit are similar in that they both establish an individual's legal immigration status in the U.S. A Permanent Resident Card confirms the holder's ability to live and work permanently in the United States, while the affidavit might be used to ascertain eligibility for certain public benefits or services based on immigration status. Each of these documents serves as a crucial piece of identification for their respective purposes, with stringent requirements for the information that must be provided and verified.

Dos and Don'ts

When it comes to filling out the Applicant Status Affidavit form, accuracy and truthfulness are paramount. This document is a critical piece of any application process for public benefits in the United States, serving as a declaration of the applicant's status. To ensure a smooth and compliant process, here are six dos and don'ts to consider:

  • Do thoroughly review the entire form before beginning to fill it out. This step ensures you understand all the requirements and have all necessary information on hand.
  • Do provide your full legal name and Social Security Number exactly as they appear on your official documents. Any discrepancies can lead to delays or rejections of your application.
  • Do choose the correct status under item #3 that accurately represents your current legal status in the United States. This information is vital for determining your eligibility for the public benefit you are applying for.
  • Do not leave any sections blank if they are applicable to your situation. Incomplete forms can be grounds for denial of the application. If a section does not apply, it is appropriate to enter "N/A" or "Not Applicable."
  • Do not attempt to provide false information or forge documents in support of your application. As clearly stated in the affidavit, knowingly doing so is a violation of law and is subject to criminal prosecution.
  • Do not forget to sign and date the affidavit. An unsigned affidavit is considered invalid and will not be processed. Your signature is your attestation that the information provided is accurate and true to the best of your knowledge and belief.

Filling out the Applicant Status Affidavit with honesty and accuracy not only fulfills your legal obligations but also facilitates a smoother verification process, helping to ensure that you receive the benefits for which you are eligible without unnecessary delay.

Misconceptions

When it comes to completing the Applicant Status Affidavit form, there are several misconceptions that can lead to confusion or errors. Understanding these common misunderstandings can help ensure the form is completed accurately and efficiently. Here are five misconceptions and the truth behind each:

  • Only U.S. citizens need to complete the form. This is incorrect. The form must be completed by anyone applying for a public benefit, which includes U.S. citizens, legal permanent residents, and qualified aliens or non-immigrants under the federal Immigration and Nationality Act. The purpose is to affirm the applicant's status and eligibility.
  • Any form of identification is acceptable. This misconception can lead to the rejection of the affidavit. The form specifies that an unexpired government-issued picture identification is required. It lists acceptable forms of identification, such as an unexpired U.S. passport or state driver’s license, among others.
  • The affidavit does not require personal details like date of birth or Social Security Number. In reality, both your full name and Social Security Number are essential parts of the affidavit. These details, along with your date of birth and country of origin, are critical for verifying your identity and eligibility for the benefit you are applying for.
  • Non-citizens do not need to provide additional documentation. On the contrary, non-citizens must provide specific documentation based on their status. For instance, if you are not a U.S. citizen, you are required to present an unexpired Employment Authorization Document or other pertinent document such as an Alien Registration Number or Passport Number. This ensures the verification of your lawful presence in the United States.
  • The affidavit allows for any information regarding your immigration status to be shared freely. This is a serious misunderstanding. By signing the affidavit, you are specifically waiving confidentiality provisions of the Immigration Reform and Control Act of 1986 (IRCA) only to the extent that it permits the Department of Homeland Security to provide information about your alien status to the Georgia Department of Labor for the purpose of determining eligibility for unemployment insurance benefits. It does not constitute a blanket permission for all your immigration details to be made public or shared beyond the scope outlined in the form.

It's crucial to approach the Applicant Status Affidavit form with clear understanding and accurate information. Misconceptions can lead to unintended mistakes. Remember, when in doubt, review the instructions provided with the form carefully or seek assistance to ensure your application process is smooth and compliant.

Key takeaways

Filling out an Applicant Status Affidavit correctly ensures applicants convey their eligibility for public benefits with accuracy. Here are four key takeaways from completing and utilizing the form:

  • Applicants are required to declare their citizenship status truthfully: they must specify whether they are a U.S. citizen, a legal permanent resident, or a qualified alien/non-immigrant under the federal Immigration and Nationality Act. This declaration is crucial for determining their eligibility for public benefits.
  • The necessity of an unexpired government-issued picture identification is emphasized to support the information provided, including one's full name and Social Security Number. This acts as a verification of identity and is mandatory for all applicants.
  • For non-citizens, providing an Alien Registration Number and the type of document that verifies their legal status (e.g., Permanent Resident Card, Employment Authorization Document) is mandatory. This information is essential for the specific determination of eligibility for non-citizens under the stated laws.
  • The form contains a consent clause where applicants voluntarily waive confidentiality provisions under the Immigration Reform and Control Act of 1986, allowing the Department of Homeland Security to share information regarding their alien status with the Georgia Department of Labor. This underlines the importance of understanding the implications of submitting the form, primarily regarding privacy and information sharing.

The Applicant Status Affidavit form serves a critical function in the assessment of eligibility for public benefits, ensuring that applicants are aware of the importance of providing accurate and verifiable information about their status. By meticulously completing this form, applicants contribute to a streamlined process for verifying eligibility, underpinning the process with integrity and transparency.

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