Free affidavit of identity 09Free affidavit of identity 09
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STATE OF GEORGIA

)
) AFFIDAVIT RE: PERSONAL IDENTIFICATION
COUNTY OF____________ )
FOR LICENSURE/REGISTRATION
PERSONALLY APPEARED before the undersigned officer, duly authorized to
administer oaths, came the undersigned, who after having been duly sworn, states under
oath the following:
1. That my name is _____________________and that I am who I say I am;
2. That my address is ____________________________________________;
3. That I have presented sufficient identification to the notary that is true and
accurate;
4. That I am legally in the United States of America;
5. That I am applying to the Georgia Department of Human Services, Office of
Residential Child Care, to operate a business/activity to be located at the following
address: __________________________________________________
that subject to regulation by the Department of Human Services and that this
affidavit is a material part of the application; and

6. That if the Department subsequently determines that the material infor