Applicant Status Affidavit PDF Details

The Applicant Status Affidavit (DOL-1054A) is a mandatory legal document issued by the Georgia Department of Labor. Under the Official Code of Georgia Annotated (O.C.G.A. 50-36-1), any individual seeking state-administered public benefits must complete this sworn declaration. The document confirms the applicant's identity and lawful presence in the United States. It applies to programs administered by the Georgia DOL and related state agencies. For other Georgia government documents, visit our Georgia Department of Labor forms page.

To complete the Applicant Status Affidavit, you must provide: your full legal name, Social Security Number, country of birth, and valid photo identification. You must declare your citizenship status as a U.S. citizen, legal permanent resident, or qualified alien under federal immigration law. Non-citizens must present an unexpired employment authorization document or another valid form of lawful presence documentation. The affidavit also includes a consent section that authorizes disclosure of your immigration status to relevant government agencies to confirm benefit eligibility.

Accuracy on this form is critical. Under O.C.G.A. Code Section 16-10-20, falsifying any information on the Applicant Status Affidavit is a criminal offense with serious legal consequences. After completing and signing the form, submit it to the claims taker or agency processing your public benefit application. If you need related documentation, our affidavit forms library includes additional resources for identity and legal status verification.

QuestionAnswer
Form NameApplicant Status Affidavit
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesapplicant status affidavit, bybadd cwb date, unemployment affidavit georgia, georgia status affidavit form

Form Preview 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

How to Edit Applicant Status Affidavit Online for Free

Completing the Applicant Status Affidavit online is quick and straightforward using our PDF editor. Follow the steps below to prepare your document accurately.

Step 1: Press the "Get Form Now" button to open the Applicant Status Affidavit in the online editor.

Step 2: Once the Applicant Status Affidavit opens in the editor, the top toolbar provides all tools needed to fill out, sign, and edit your form.

The following sections make up the PDF document:

applicant status affidavit empty spaces to fill out

The form requires you to complete fields for Unexpired Employment Authorization, Alien Registration Number, Citizenship Certificate, Naturalization Certificate, SEVIS ID, Expiration Date, Passport details, and the Consent to Disclosure section.

Filling in applicant status affidavit step 2

Provide your Applicant Signature, Claims Taker Signature, and Employee ID digits. Complete the certification fields, including the Employment Eligibility Date and any secondary verification information required.

Filling out applicant status affidavit part 3

In the identity verification section, enter your full name and initials. Then select one secure and verifiable document from the following: an unexpired U.S. passport, state-issued driver's license, state identification card, or tribal identification card. For a related identity protection form, see the FTC identity theft affidavit.

Completing applicant status affidavit stage 4

Complete the remaining documentation fields by providing one of the following acceptable documents: an unexpired tribal identification card, U.S. passport, Employment Authorization Document, Merchant Mariner Card, NEXUS card, SENTRI card, driver's license, Certificate of Citizenship, or Certificate of Naturalization.

applicant status affidavit An unexpired tribal identification, An unexpired United States, An unexpired Employment, An unexpired passport issued by a, An unexpired Merchant Mariner, An unexpired Free and Secure Trade, An unexpired NEXUS card, An unexpired Secure Electronic, An unexpired drivers license, A Certificate of Citizenship, and A Certificate of Naturalization blanks to complete

Step 3: Click "Done" when finished. You can now export the completed Applicant Status Affidavit as a PDF.

Step 4: Save at least one copy of the completed form before submitting it to the Georgia Department of Labor or the relevant benefits agency.

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