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When individuals apply for public benefits, they must often navigate through various forms and documents, one of which is the Applicant Status Affidavit form. This form plays a critical role in ensuring that applicants clearly state their identity, citizenship status, and eligibility for the benefits they seek. It requires applicants to provide substantive information, such as their full name, social security number, and an unexpired government-issued photo ID, to affirm their identity. Additionally, it includes sections where individuals must disclose their country of birth and confirm their age, highlighting the form’s attention to detail in confirming eligibility criteria. Most importantly, the affidavit requires individuals to declare their citizenship or immigration status, choosing from options that include being a U.S. citizen, a legal permanent resident, or a qualified alien or non-immigrant under U.S. immigration law. This declaration is not taken lightly; the form necessitates that all non-citizens provide specific immigration documents. Moreover, it outlines the implications of confidentiality waiving, allowing the Department of Homeland Security to share information with the Georgia Department of Labor to verify eligibility for unemployment insurance benefits. The form sternly warns against false statements, emphasizing the legal consequences of fraud. This affidavit not only assists in the process of benefit application but also plays a vital role in maintaining the integrity and fairness of the system, ensuring that assistance reaches those who are rightfully eligible.

Document Sample

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

File Attributes

Fact Name Description
Governing Law O.C.G.A. 50-36-1
Applicant Requirements Must provide full name, Social Security Number, and unexpired government-issued picture identification.
Age Requirement Applicant must be 18 years of age or older.
Citizenship Declaration Applicant must declare U.S. Citizenship, legal permanent residency, or qualified alien status under the Immigration and Nationality Act.
Non-Citizen Documentation Non-citizens must provide an Unexpired Employment Authorization Document and relevant identification numbers.
Consent to Disclosure Applicant waives confidentiality under IRCA for DHS to provide immigration status to the Georgia Department of Labor.
Penalty for False Statements Making false, fictitious, or fraudulent statements or representations is a violation subject to criminal prosecution under state and federal laws.

Guidelines on How to Fill Out Applicant Status Affidavit

Filling out the Applicant Status Affidavit form is a necessary step for those seeking certain public benefits, ensuring that applicants declare their eligibility status accurately. This form demands attention to detail, as it involves providing personal identification and immigration status information. To complete this form correctly, applicants should gather relevant documents beforehand, such as a government-issued identification and any applicable immigration documentation. Following these steps methodically will lead to a smoother process and ensure the accurate representation of one’s eligibility status.

  1. Start by entering the current date at the top of the form where it says "Date."
  2. Fill in the county name in the space provided where it says "COUNTY OF."
  3. Under the section "Comes now the undersigned," write your full legal name where it indicates "My full name is" and include your Social Security Number in the space provided.
  4. Attach or provide your unexpired government-issued picture identification, as it supports your declaration of name and identity.
  5. State your birth country and date of birth in the designated spaces. Ensure that you are at least 18 years of age or older, as this is a requirement.
  6. Initial next to the correct status declaration that applies to you: U.S. Citizen, legal permanent resident, or a qualified alien/non-immigrant under the federal Immigration and Nationality Act.
  7. If you are not a U.S. Citizen, you must provide details of your unexpired Employment Authorization Document, including any relevant identification numbers like Alien Registration Number, and the expiration date of the document.
  8. Read and understand the Consent to Disclosure section. By signing the affidavit, you agree to waive certain confidentiality provisions for the purpose of verifying your eligibility for the public benefit.
  9. Review the section regarding the criminal prosecution for false statements on the affidavit. Acknowledging this is critical, as providing false information can result in legal consequences.
  10. Sign the affidavit in the space provided under "Applicant Signature." This act affirms that all the information provided is true and accurate to the best of your knowledge.
  11. If required, allow the claims taker to sign the form and provide their Employee ID# in the designated spaces.
  12. Finally, complete any additional information that may be required by the central office, including certification numbers, eligibility dates, and verification checks.

Upon completing the Applicant Status Affidavit form, review all the information for accuracy. It's important that every detail is correct, as this document plays a critical role in determining your eligibility for certain public benefits. With all sections accurately filled, submit the form to the designated department or authority overseeing your application. Keep a copy of the completed affidavit for your records.

Discover More on Applicant Status Affidavit

What is the purpose of the Applicant Status Affidavit form?

The Applicant Status Affidavit form is designed to verify the identity and legal status of individuals applying for public benefits. By providing detailed personal information, including citizenship or immigration status, applicants demonstrate their eligibility to receive these benefits under the laws governing the state and federal regulations.

Who needs to complete the Applicant Status Affididavit form?

Any individual who seeks to obtain a public benefit, which requires validation of their identity and legal status in the United States, must complete the Applicant Status Affidavit form. This includes U.S. citizens, legal permanent residents, and non-immigrants who are lawfully present in the U.S. under the federal Immigration and Nationality Act.

What documentation is required to accompany this affidavit?

All applicants are required to provide an unexpired government-issued photo identification. Non-citizens must also provide additional documentation, such as an Alien Registration Number or other specific identification numbers linked to their immigration status, to support their application.

Is there an age requirement for applicants submitting this affidavit?

Yes, only individuals who are 18 years of age or older are eligible to submit this affidavit. It's crucial for the applicant to verify their age along with their legal status when applying for public benefits.

What happens if an applicant provides false information in the affidavit?

Knowingly and willingly making a false, fictitious, or fraudulent statement or representation in this affidavit is a serious offense. It violates O.C.G.A. Code Section 16-10-20 and subjects the applicant to criminal prosecution under state and federal laws. It is imperative for all the information provided to be accurate and truthful.

Can non-citizens apply for public benefits through this affidavit?

Yes, non-citizens who are legal permanent residents, qualified aliens, or non-immigrants lawfully present in the United States under the federal Immigration and Nationality Act may apply for public benefits. However, they must provide specific documents to verify their status, as listed on the affidavit form.

How does an applicant consent to the disclosure of information?

By signing the Applicant Status Affidavit form, an applicant freely and voluntarily waives the confidentiality provisions of the Immigration Reform and Control Act of 1986 (IRCA). This waiver allows the Department of Homeland Security (DHS) to provide the Georgia Department of Labor with information regarding the applicant’s alien status for purposes of determining eligibility for unemployment insurance benefits.

What types of documents are considered secure and verifiable?

The form lists specific documents that are recognized as secure and verifiable. These include an unexpired U.S. passport, driver’s license, or military identification card, among others. For non-citizens, acceptable documents include an unexpired Permanent Resident Card, Employment Authorization Document, or a valid passport issued by a foreign government with a federal form evidencing lawful immigration status. All documents must be unexpired and contain enough information to establish the bearer’s identity.

Common mistakes

When filling out the Applicant Status Affidavit form, individuals often make mistakes that can delay or impact their application negatively. Ensuring accuracy and completeness when completing this form is critical. Here are eight common errors to avoid:

  1. Not providing full legal name clearly and exactly as it appears on their government-issued identification.
  2. Failure to include a Social Security Number or incorrectly entering the Social Security Number.
  3. Overlooking the requirement to check a box to declare status - U.S. Citizen, legal permanent resident, or qualified alien/non-immigrant.
  4. Omitting the Alien Registration Number or other identification number for non-citizens, which is crucial for verification of legal status.
  5. Forgetting to include or incorrectly filling out the expiration date for pertinent identification documents, especially for non-citizens.
  6. Neglecting the Consent to Disclosure section, which is essential for the Department of Labor to verify alien status with the Department of Homeland Security.
  7. Providing an incorrect date of birth or mismatching the date of birth with that on legal documents, leading to issues in identity verification.
  8. Signing the affidavit without ensuring that all the information provided is true, correct, and complete can lead to prosecution for providing false information.

Avoiding these mistakes is key to a smooth process. Applicants should double-check their information, pay attention to detail, and provide all required documentation to prevent unnecessary delays or legal issues.

Documents used along the form

When navigating the legal requirements for obtaining a public benefit, the Applicant Status Affidavit form serves as a crucial first step in affirming an individual's eligibility based on citizenship or immigration status. However, this form rarely stands alone in the application process. A series of other forms and documents often accompany it, each playing a vital role in painting a complete picture of the applicant's qualifications. Let's explore some of these essential documents.

  • Proof of Identity: An unexpired, government-issued photo ID, such as a passport or driver’s license, confirms the applicant's identity, aligning with the information provided in the affidavit.
  • Birth Certificate: This certifies the applicant's birthplace and age, crucial for verifying eligibility for benefits that have age or nationality requirements.
  • Social Security Card: Often required to validate the applicant's social security number, enabling the authorities to check eligibility for benefits and other legal matters.
  • Employment Authorization Document (EAD): For non-citizens, an EAD proves the individual's right to work in the United States, a necessity for some types of public benefits.
  • Certificate of Naturalization or Citizenship: These documents serve as proof of U.S. citizenship for individuals not born in the United States, supplementing the affidavit where an applicant claims citizenship.
  • Permanent Resident Card: Also known as a Green Card, it’s crucial for legal permanent residents to demonstrate their status when applying for benefits requiring such eligibility.
  • Alien Registration Receipt Card: This serves as identification and proof of the right to live and work in the United States permanently for non-citizen residents.
  • Proof of Residence: Current utility bills, lease agreements, or mortgage statements help confirm the applicant’s residency within a specific jurisdiction or state, which may be necessary for state-specific benefits.
  • Tax Return Documents: Recent tax returns can establish income levels, which are often a criterion for qualifying for various public benefits, demonstrating the applicant’s financial need or eligibility.

Together, these documents form a comprehensive package that validates the claims made in the Applicant Status Affidavit form. By meticulously preparing and presenting these forms and documents, applicants increase their chances of successfully navigating the complex process of obtaining public benefits. Ensuring each document is current, accurately filled out, and properly submitted alongside the affidavit lays a solid foundation for a positive outcome in the application process.

Similar forms

The Declaration of Domicile form shares similarities with the Applicant Status Affidavit as both documents serve to verify an individual's residence and status. The Declaration of Domicile primarily confirms a person's physical presence and intent to make a certain location their permanent home, often required by state entities to establish residency. Like the Applicant Status Affidavit, it involves a formal declaration, providing identifiable information to authenticate the claim within a legal framework.

An Employment Eligibility Verification Form (I-9) is akin to the Applicant Status Affidavit through its focus on legal status for employment purposes. This form is used by employers to verify an employee's identity and to establish that the worker is eligible to accept employment in the United States. Both documents necessitate the presentation of personal and, if applicable, immigration status information, underscoring their roles in compliance with U.S. laws.

The Non-Driver Identification Card application is another document that mirrors the Applicant Status Affidavit, as both are utilized for identification verification processes. While the Non-Driver ID helps individuals without a driver's license obtain a form of state-recognized identification, the Affidavit supports the verification process for accessing public benefits, requiring proof of identity and citizenship or legal presence in the country.

The U.S. Passport Application bears resemblance to the Applicant Status Affidavit by serving as a means to verify one's identity and citizenship. Though the primary aim of a passport is to facilitate international travel, it entails a detailed verification process similar to the Affidavit's, requiring applicants to provide comprehensive personal information, evidence of U.S. citizenship, and identity documents.

The Voter Registration form parallels the Applicant Status Affidavit in its requirement for individuals to provide personal information and affirm their citizenship status before participating in the electoral process. Both documents involve declarations under oath about the applicant's eligibility for a public benefit, be it the right to vote or to receive a state-provided service, necessitating accurate and truthful information.

A Rental Application often necessitates disclosure of similar types of information as the Applicant Status Affidavit, such as identity, previous addresses, and sometimes even citizenship status to ensure eligibility and reliability of a potential tenant. Though serving different purposes—one for housing and the other for accessing public benefits—both require applicants to provide detailed personal information for verification purposes.

The Social Security Card Application process is akin to that of the Applicant Status Affidavit since both require substantiation of identity, citizenship, or legal immigration status. Applying for a Social Security number involves rigorous documentation to verify one's eligibility, paralleling the affidavit's requirement to establish legal presence for accessing public benefits.

The Marriage License Application, similar to the Applicant Status Affidavit, demands comprehensive personal information from individuals to certify the legality of their union. Both forms require declarations and personal details to authenticate eligibility—be it for marriage or for receiving benefits—within a legal and official capacity.

Lastly, the Naturalization Application (Form N-400) shares objectives with the Applicant Status Affidavit by necessitating thorough proof of identity, residency, and eligibility for a new status, in this case, U.S. citizenship. Each document is part of a procedural requirement to ascertain an individual’s legal standing and eligibility for certain rights and benefits granted by the government.

Dos and Don'ts

When filling out an Applicant Status Affidavit form, it is crucial to approach the task with careful attention to detail and integrity. Below is a list of dos and don'ts that can help ensure the process is completed accurately and lawfully.

  • Do read the entire form before starting to fill it out. Understanding the scope and requirements of the form beforehand can prevent mistakes.
  • Do verify that all personal information is correct and matches the details on your official documents. This includes your full name, Social Security Number, and date of birth.
  • Do provide accurate and current proof of identity and legal status, attaching unexpired government-issued identification as required by the form.
  • Do carefully select the appropriate status box that accurately represents your current legal or immigration status. This decision must align with your actual circumstances and legal documentation.
  • Do sign and date the affidavit in the designated sections, acknowledging that you are aware of the form's legal implications and asserting the truthfulness of the information provided.
  • Don't leave any fields blank. If a section does not apply to you, fill it with "N/A" to indicate this clearly and avoid any appearance of oversight.
  • Don't guess or approximate information. If you are unsure about specific details or documentation numbers, take the time to verify them before submission.
  • Don't use expired identification or documents to support your affidavit. The form specifies that all documentation must be current and valid.
  • Don't attempt to alter or falsify information in any way. Misrepresentation on this affidavit can lead to criminal prosecution, as it is a serious offense against state and federal laws.

Filling out an Applicant Status Affidavit requires a clear understanding of one's legal status and careful attention to the accuracy of the information provided. By following these guidelines, applicants can help ensure that their affidavit accurately reflects their entitlement to the public benefits they are seeking.

Misconceptions

When navigating the complexities of legal documents, especially those as crucial as the Applicant Status Affidavit required in certain states for accessing public benefits, misinformation can easily spread. Let's clear the air about some common misconceptions concerning this document.

  • It's only for non-citizens. A major misconception is that the Applicant Status Affidavit is exclusively for non-citizens. In reality, this document requires all applicants, whether they're U.S. citizens, legal permanent residents, or qualified aliens, to affirm their eligibility for public benefits. This ensures that benefits are dispensed fairly and according to the law.

  • Every state requires it. Not all states have the same requirements for obtaining public benefits. The Applicant Status Affidit, referenced with respect to Georgia law (O.C.G.A. 50-36-1), is not a uniform federal requirement but a state-specific one. It's crucial to check the requirements in your specific state.

  • Any ID will work for verification. The document lists specific types of identification that are considered "secure and verifiable" under Georgia law. Not just any identification will suffice. Acceptable documents include unexpired U.S. passports, military IDs, and others as outlined in the form. Each has to contain certain information to be acceptable.

  • Submitting the form grants immediate access to benefits. Filling out and submitting the affidavit is just one step in the application process for public benefits. Applicants must still meet all other eligibility requirements set by the specific program they are applying for.

  • A social security number is always required. While U.S. citizens will provide their social security number, non-citizens are asked to provide a range of different identifiers, such as an Alien Registration Number or a Naturalization Number, depending on their specific immigration status.

  • The form is a declaration of financial status. Despite the "affidavit" aspect, this form primarily focuses on confirming the applicant's citizenship or immigration status, not their financial situation. Other parts of a benefit application typically address financial eligibility.

  • Children under 18 can sign it. The affidavit clearly states that the applicant must be 18 years of age or older. Thus, an adult guardian or parent would need to affirm the status of minors when applying for benefits on their behalf.

  • The waiver of confidentiality affects all personal information. Consent to disclosure specifically allows the Department of Homeland Security to share information regarding an individual's alien status with the Georgia Department of Labor. It’s a targeted waiver, not an unconditional release of all personal information.

  • It's a permanent document. Like many parts of the application process for public benefits, the status affidavit is periodically updated to reflect changes in an individual’s circumstances or updated legal requirements. It's not a "fill it once and forget it" document.

  • Misrepresentations are a minor issue. Knowingly making a false statement on this affidavit is a crime under both state (O.C.G.A. Code Section 16-10-20) and potentially federal law. It carries serious consequences, emphasizing the importance of accuracy and honesty in its completion.

Understanding these points about the Applicant Status Affidavit can help applicants ensure that they're correctly navigating the process for accessing public benefits, reducing the potential for errors and legal issues.

Key takeaways

Filling out the Applicant Status Affidavit form accurately is critical for applicants seeking public benefits. Below are key takeaways to help guide you through the process:

  • Ensure that your full name and Social Security Number are entered exactly as they appear on your social security card to prevent any discrepancies.
  • Providing valid, unexpired government-issued photo identification is mandatory to support the declaration of your name and identity.
  • If you are not a U.S. citizen, you must indicate whether you are a legal permanent resident or a qualified alien or non-immigrant under the federal Immigration and Nationality Act, and provide appropriate documentation.
  • All non-citizens must furnish details of their unexpired Employment Authorization Document, including Alien Registration Number and expiration date.
  • By signing the affidavit, you consent to waive the confidentiality provisions of the Immigration Reform and Control Act of 1986, allowing the Department of Homeland Security to share information about your alien status with other government departments.
  • Making a false, fictitious, or fraudulent statement or representation in this affidavit is illegal and subject to criminal prosecution.
  • The affidavit must be signed by the applicant and a claims taker, with the latter's employee ID number included for verification purposes.
  • There's a space provided for central office use only, which includes certification, employment eligibility date, and a section for secondary verification remarks.
  • The form lists secure and verifiable documents accepted under the law, ensuring you provide one of the listed items for identity verification purposes.

It's crucial to approach this application with attention to detail and honesty to ensure compliance and verify eligibility for the benefits you're applying for.

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