|
DocuSign Envelope ID:2E5A8509-E4CD-4A45-9241-C69B05F6A27D
<br /> STATE OF NOR1 li CAROUNA
<br /> FY AFFIDAVIT
<br /> ORANGE COUNTY
<br /> .44,4,-4 444 4 4 4+.4 4.4,444
<br /> InOVid(131 fittkOStihS be?oWfr be'rng.duly. Authorited by And on behaff of
<br /> entity bidding'On project hereinafter"Employee)after firitlufing dub/
<br /> sworn hereby swears or Affirrn!.as foltomr
<br /> 1. Employer understands that gfverify is the federal E-Verify program operated by the United States
<br /> Oeptvt merit of HomoIrld Socwity And other fodoe40 opeAcio,or Any Sigtk2Vice-Or equi\•aient progrom tgod to v*rify
<br /> the work 4.i.ithoriV3k)f) of newsy hired employees p;frovont tc fetiefal iaW In afxbrderroe with NOS§644$(5),
<br /> EmPloro kindfl--ftaltd-1 that PDPIAM-U.tisl.MAt_APJ:..,..Vogt fAch onvloyv, after hiring-an employee to work
<br /> ii to United $t4tos,4hilli.,,iarifi;the work-au thoriza tir,,n of the employee theough e-vwqy I n DCr0rthirlai t.,4th
<br /> CG-S8426(
<br /> 3, Ernployer is a person,business entity,or other organization that trans-ads business in this State and that
<br /> employs 25 oi more employees in this State. (mark Yes or No)
<br /> a. YES , or
<br /> b. NO
<br /> 4., Ernployer'$$e bcorwatturs cormay with E.-1.1erifyi toci.3f Employe; 14-the veHung ' idder on th-1 popact:
<br /> Empiotror win (,,nut Qcopie,,,0 with E-Vo rify by onyx subcontractora t,theocitiontly hired by fire pioyor.
<br /> ,
<br /> Trris day of Jc--- '
<br /> .., „,„...,....„....,......—.....,,,...„-„,....„..„
<br /> Signature of ATf: t—
<br /> 7
<br /> Print or Type Name: 1:- ,.!,?,,:E.:-2.-c„,___,1::■„,. .11.,m,,, ,,L .
<br /> slew of t9.9xtb,.00di go. ()tango County
<br /> ,...,
<br /> -,.. .q).
<br /> Signed and s\trorn tolor affirmed) before me,this the
<br /> day of, bf Air' ,
<br /> „24-1-37. W
<br /> tg ,
<br /> sfro v 1
<br /> ,0 Iso-
<br /> My Commission Expires: ry.
<br /> .
<br /> / , ,,,,
<br /> _.5...1,161-Z0-11---- •-,,...-------- .If edi-
<br /> Seet M_ p
<br /> . eAswEvt-
<br /> . _
<br /> Notary Pubic
<br />
|