University System of Georgia

(Suggested) Admissions applicant affidavit of eligibility

I hereby swear and attest to eligibility for federal or state and local public benefits.

By executing this affidavit under oath, as an applicant for admission into the University System of Georgia as a student, I swear the below information is true and correct.

_____ I am a United States citizen

Verifying documents submitted:

_____ Notarized copy of U.S. issued birth certificate

_____ Certificate of U.S. Naturalization (copy)

or

_____ I am a Legal Permanent Resident, qualified alien or non-immigrant under the Federal Immigration and Nationality Act and lawfully present in the United States according to its laws.

Alien Registration Number _________________

Verifying documents submitted:
(A front and back copy of one of the following documents must be attached)

(Check one)
______ Valid foreign passport with I-94 form attached or,
______ Temporary Resident Alien Card (I-688) or,
______ Employment Authorization Card/Document (I-766 or I-688B) or,
______ Refugee Travel Document (I-571)

In making the above representation under oath, I understand that any person who knowingly and willingly makes a false, fictitious or fraudulent statement or representation in an affidavit shall be guilty of a violation of 16-10-20 of the Official Code of Georgia.

I also understand that whoever knowingly makes any false statement under oath, in any case, proceeding, or matter relating to, or under, or by virtue of any law of the United States relating to naturalization, citizenship, or registry of aliens shall be fined or imprisoned not more than five years, or both under federal statute. (18 USC 1015 – Sec. 1015. Naturalization, citizenship or alien registry)

Sworn and subscribed

_____________ Signature of applicant _____________ Print name

Before me this _____day of 20____ SEAL

_______________Notary Public My commission expires: ______________

All non-citizens eligibility information shall be verified using the federal SAVE database.

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