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Get Ga Gid-276-en 2012

Ecuting this affidavit under oath, as an applicant for a license, certificate, registration, permit, etc., as referenced in O.C.G.A. §50-36-1, from the Office of Insurance, Safety Fire and Industrial Loan Commissioner, the undersigned applicant verifies one of the following with respect to my application for a public benefit: [Check ONLY ONE of the following:] 1) _________ I am a United States citizen; OR 2) _________ I am a legal permanent resident of the United States; OR My alien number i.

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