Form DOL-1054A at a glance
What it is: Applicant Status Affidavit: the undersigned, upon oath, states that they are an applicant for a public benefit and are making the representations in the affidavit to obtain that public benefit.
Who signs: Sign at Applicant Signature.
A filled-in Form DOL-1054A example: a U.S. citizen fills out the affidavit
How to fill out Form DOL-1054A, box by box
STATE OF and COUNTY OF
Enter the STATE OF and the COUNTY OF at the top.
Number 1, full name and Social Security Number
At number 1, enter your full name and your Social Security Number.
Provide your unexpired government-issued picture identification in support of this declaration of your name and identity.
Number 2, born in and 18 years of age or older
At number 2, enter the NAME OF COUNTRY you were born in on / /, and you are 18 years of age or older.
Number 3, citizen, permanent resident or qualified alien
At number 3, initial one: that you are a U.S. Citizen; OR that you are a legal permanent resident; OR that you are 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.
Number 4 for all non-citizens
Number 4, an unexpired Employment Authorization Document, is required of all non-citizens: if you indicated other than United States citizenship in item 3, enter your Alien Registration Number issued by the Department of Homeland Security or other federal immigration agency or other number.
Enter the Alien Registration #, Card #, Citizenship Cert #, Passport # (with), (or) Naturalization #, I-94 Stamp #, SEVIS ID #, I-551 Stamp # and Expiration Date, I-94 #.
Signing the affidavit
Number 6: you 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. You swear or affirm that the citizenship and other information you have provided here is true and correct to the best of your personal knowledge and belief.
Sign at Applicant Signature.
The Claims Taker Signature, its Employee ID# and For Central Office Only are not yours to fill.
More rules for Form DOL-1054A
Number 5, Consent to Disclosure: you 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 your alien status for purposes of determining your eligibility for unemployment insurance benefits. You understand that IRCA precludes DHS from using, publishing, or making available information related to your application for adjustment to temporary residence except as provided by law (confidentiality provision).
Page 2 has Name, SSN and Initials. Secure and verifiable documents under O.C.G.A. 50-36-2: an unexpired United States passport or passport card or an unexpired United States military identification card.
An unexpired driver's license or 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.
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.
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), Certification of Birth Abroad issued by the United States Department of State (Form FS-545) or Consular Report of Birth issued by the United States Department of State (Form FS-240), each 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.
Sources
[1] Form DOL-1054A (R-3/20), Applicant Status Affidavit, Georgia Department of Labor (the Official source link on this page).
