DPH Contractor Affidavit Under O C G a 13 10 91 9b 1

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ATTACHMENT 4
Contractor Affidavit under 0.C.G.A. § 13-10-91(b)(1)

By executing this affdav, the undersigned contractor verfles its compliance wth O.C.G.A. §
13-101, stating afmatvely tht the Indivua, fm or corporation which seeks to id or sign a
contract fr the performance of labor or services on behalf ofthe, Georgia Department of Public
Health, has register wih, s authorized to use and uses the federal work authorization program
commonly known. as E-Veriy, or ary subsequent replacement program, in accordance Wit te
applicable provisions and deadines estabished In OCGA. § 13-1091. Furtwomore, the
Undersigned conracior wil conti to use the federal work authorization program throughona the
Contract priod and the underigned contractor wil contrac forthe performance of labor of services
in satisfaction of such contract ony with subcontractors who present an afdavt to the contractor
ih the information requited by 0.6.G.A. § 13-10-01(0)- Contractor hereby attests thats federal
‘work authorization user Wentifeation number and date of authorization ae as flows:
45524-5550

Federal Work Authorization User Weriication Number
Bl25/16

et eel

SKILLS AND KNOWLEOG E FOR THE F

"Name of Gonrador and PARgAIMG.

POSITIVE ALTIERNATINES FOR PREOWANOY FT URE

eae =
SEIS AND KNOWLEDGE FOR THE HOMebAA:/NC-

“Name of Public Employer

TURE INC:

| hereby declare under penalty of perjury thatthe foregoing is true and correct.

tris OT aayor AuGEST _ , 200

“Signature of Authorized Officer or Agent

SopitiA _FACEY

Printed Name and Tile of Authorized Officer or Agent

Qo

Subscribed before me this AS aay or Aware?
° ot

NOTARY PUBLIC
My Commission Expres: /0-S- 20/77 _

IDPH Form CG09008A (Rev. 7.2013): For use with contracts for labor or services of $2500 or
more]