Preview SPD SP054
ATTACHMENT 4 Contractor Affidavit under 0.0..A. § 1340.91(b)(1) By executing ths affidavit he undersigned! co-trestor vars its compliance with 0.0.6.4. § 13-19-64, stating allimalWvaly that the Individual, fim 2 cowporalion wshich seeks to bid or sign 2 conlrset for the perforsanca o labor of servioes on behalf ef the Georgia Depariment of Pure Heel has zogislered si, is authorized fo use anc uses tre faderal wark acthorizsbon program sommonly known ae E-Verfy, or any subsequent replzcainart program, i: ecsordenoe wih tha appicabe provisions and deacines established in OCGA § 134081. Furthermore, the Undersigned contactor will cantinue to use the federal werk authosizator. progiem ffraugnout tha ‘contact period ara be undersigned contactor wis contact fe the perfomance of Iebor or services in setisiaction of suth contract enly wich eubcontracors who prascit a” afficad fo the convactor ‘with the information required by O.C.G.A, § 19-10-01(b). Contractor hereby attests vats federal ‘work auttorizalin User Warieaion nurnbe’ and date of authorization are as fo. ows: 811316. Ferieral Werk Augforaton User lenttialion Number ogyoay1a Date of Authorization Colubus Wellasve Ooater Gutrench & Praventtem Project, Iie Name of Contractor TREE of Georgia Wane of Pre Na | heseby declare sndar penalty of perjury hal th forcgalng i tue and comect thie 28th dayot Soplerber 2018 Py hi Afra Bn Serer aan Sree anc Inel la Rhodes Director Plated Name and Tile of Autibvizad Ollear of Agent ra 1 A subscribed netore me thie 224 day ot gslene <A q : wd feng rs Ly Conimission pias: Age: pies ofl tO GP {OPH Forn CG09008A (Rev, 7.2013). For use with seskacis far labor oF senviona of $2500 or moral Aor’
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