Applicant Status Affidavit PDF Details

The Form DOL-1054A requires the job applicant to attest, under penalty of perjury, to their work authorization status. Specifically, the form requires the applicant to provide their name, address, date of birth, social security number, and to attest whether they are a United States citizen, a lawful permanent resident, authorized to work in the United States, or not authorized to work in the United States.

Employers are required to keep a copy of the Form DOL-1054A in the employee's personnel file throughout their employment and for one year after the employment relationship ends. The Department of Labor may audit employers to ensure compliance with this requirement.

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

There is nothing challenging related to working with the bybadd cwb date when you launch our tool. Following these simple steps, you can obtain the prepared document within the least period possible.

Step 1: Press the "Get Form Now" button to begin the process.

Step 2: The instant you get into our bybadd cwb date editing page, there'll be all of the options you can undertake with regards to your template in the upper menu.

These particular sections are going to make up your PDF document:

applicant status affidavit empty spaces to fill out

The application will demand you to prepare the Unexpired Employment, Alien Registration, Citizenship Cert, Naturalization, SEVIS ID, Expiration Date, Card, Passport, I Stamp, I Stamp, with, Consent to Disclosure I freely, and I understand that knowingly and part.

Filling in applicant status affidavit step 2

The application will demand you to give specific fundamental info to instantly fill in the field Applicant Signature, Claims Taker Signature, Employee ID digits, For Central Office Only, Cert Secondary Verification q Yes, Emp Elig Date, and DOLA R Page of.

Filling out applicant status affidavit part 3

The Name, Initials, SECURE AND VERIFIABLE DOCUMENTS, SSN, An unexpired United States, An unexpired United States, An unexpired drivers license, An unexpired identification card, and An unexpired tribal identification area is the place to include the rights and obligations of each party.

Completing applicant status affidavit stage 4

End by analyzing these areas and completing the required details: 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.

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: Select "Done". Now you may export the PDF form.

Step 4: You will need to create as many duplicates of the form as possible to remain away from future complications.

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