Form Dol 1054 A PDF Details

In today's increasingly interconnected world, navigating the complexities of legal documents becomes paramount, especially for individuals seeking public benefits in the United States. The DOL-1054A form serves as a vital affidavit for applicants, underscoring the importance of truthful and accurate representation of one’s personal and immigration status. This form, mandated by the state, requires an individual to affirm their identity, citizenship status, and eligibility for public benefits under the law. It delineates a range of declarations, from asserting U.S. citizenship to demonstrating legal permanent residency or qualifying alien status under the Immigration and Nationality Act. Moreover, for non-citizens, it necessitates the presentation of an Employment Authorization Document, enhancing the verification process. The form also touches on the consent to disclose information to the Department of Homeland Security, aiming to facilitate the determination of eligibility for benefits such as unemployment insurance. Importantly, it underscores the legal implications of providing false information, aligning with state and federal regulations to safeguard the integrity of the process. Accompanying the affidavit, the form lists acceptable documents for proving identity and legal status, including passports, driver's licenses, and military identification cards, among others, ensuring a secure and verifiable means of application. Through these features, the DOL-1054A form embodies a comprehensive approach to affirming eligibility for public benefits, while emphasizing the importance of honesty and accuracy in legal declarations.

QuestionAnswer
Form NameForm Dol 1054 A
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesbybadd cwb date, what does this mean byb add cwb date, byb add cwb date example, byb add cwb date definition

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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 present here my 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 representations 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 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.Employment Authorization Document: REQUIRED OF ALL NON-CITIZENS. If I indicated other than United States citizenship in item #3 above, my Alien Registration Number 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 #

 

 

 

 

 

and I present the original document here for your review and copying. Copy attached [

 

]

 

 

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.

Sworn to and subscribed before me

 

 

this

day of

, 20

.

Notary Public

My Commission Expires:

Note to Notary Public: Initial space on back of form to indicate document(s) provided.

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-8/13) Side 1

Name:

 

SSN:

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

Initials:

A United States passport or passport card.

A United States military identification card.

A driver’s license issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Common wealth 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 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.

A 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.

A United States Permanent Resident Card or Alien Registration Receipt Card.

An Employment Authorization Document that contains a photograph of the bearer.

A passport issued by a foreign government.

A Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast Guard.

A Free and Secure Trade (FAST) card.

A NEXUS card.

A Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card.

A 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).

DOL-1054A (R-8/13) Side 2

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2. Once your current task is complete, take the next step – fill out all of these fields - Employment Authorization Document, Alien Registration, Citizenship Cert, Naturalization, SEVIS ID Expiration Date, Card, Passport with, I Stamp or, I Stamp, and I present the original, Consent to Disclosure I freely, and I understand that knowingly and with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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As for Employment Authorization Document and SEVIS ID Expiration Date, be sure you double-check them in this section. The two of these could be the most significant ones in this form.

3. Completing I understand that knowingly and, Sworn to and subscribed before me, Notary Public My Commission Expires, Applicant Signature, Claims Taker Signature, Employee ID digits, Note to Notary Public Initial, For Central Office Only, Cert Secondary Verification q Yes, Emp Elig Date, and DOLA R Side is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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4. To go onward, this stage requires filling out a couple of blanks. Examples of these are Name SSN, SECURE AND VERIFIABLE DOCUMENTS, Initials, A United States passport or, A United States military, A drivers license issued by one of, An identification card issued by, and A tribal identification card of a, which you'll find vital to continuing with this process.

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5. To wrap up your document, the last part features a number of extra fields. Filling out A United States Permanent Resident, An Employment Authorization, A passport issued by a foreign, A Merchant Mariner Document or, A Free and Secure Trade FAST card, A NEXUS card, A Secure Electronic Network for, A drivers license issued by a, and A Certificate of Citizenship issued should conclude the process and you're going to be done in a blink!

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