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Appendix C

Pursuant to O.C.G.A. § 50-36-1(e)(2), please complete the following Affidavit. A list of secure and verifiable documents can be found on our website. Please be sure to include the secure and verifiable document with this signed affidavit.

O.C.G.A. § 50-36-1(e)(2) Affidavit

By executing this affidavit under oath, as an applicant for a(n) State-Funded Charter School Facility Grant [type of public benefit], as referenced in O.C.G.A. § 50-36-1, from the Georgia State Board of Education [name of government entity], the undersigned applicant verifies one of the following with respect to my application for a public benefit:

1) ______I am a United States citizen.

2) ______I am a legal permanent resident of the United States.

3) ______I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an alien number issued by the Department of Homeland Security or other federal immigration agency.

My alien number issued by the Department of Homeland Security or other federal immigration agency is:______.

The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at least one secure and verifiable document, as required by O.C.G.A. § 50-36-1(e)(1), with this affidavit.

The secure and verifiable document provided with this affidavit can best be classified as:

______.

In making the above representation under oath, I understand that any person who knowingly and willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty of a violation of O.C.G.A. § 16-10-20, and face criminal penalties as allowed by such criminal statute.

Executed in ______(city), ______(state).

______Signature of Applicant

______Printed Name of Applicant

SUBSCRIBED AND SWORN BEFORE ME ON THIS THE

___ DAY OF ______, 2017

______NOTARY PUBLIC My Commission Expires:

2053 Twin Towers East • 205 Jesse Hill Jr. Drive • Atlanta, Georgia 30334 • (404) 657-0515 • Fax (404) 463-2393 • www.gadoe.org An Equal Opportunity Employer Appendix D

Agreement for Reversion of Unencumbered Funds and All Equipment and Property for State Charter Schools or Locally Approved Charter Schools

Please note that a different agreements are required for locally-approved charter schools and for state charter schools.

The appropriate agreement on the following pages must be signed by the parties indicated at the bottom of the agreement.

For locally-approved charter schools, the agreement must be signed by the charter school governing board chair and the chair of the local board of education or the Superintendent.

For state charter schools, the agreement must be signed by the charter school governing board chair.

The appropriate agreement must be fully signed and submitted with this application in order for your application to be considered for funding.

Note: The State Board of Education (SBOE) meeting date and the grant award amount will be completed by Georgia Department of Education staff upon award approval by the SBOE. A copy of the completed agreement will be returned with the award letter.

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