I, (your name) _____________________________________, certify that I am currently unemployed and have been unemployed since (month and year)__________,20_____, and have not received income from any of the following sources: Self-Employment Income, Workers Compensation, Social Security Benefits, Alimony or Separation Payments, Retirement Payments, Pensions or Annuity Income, Disability Payments, Unemployment Benefits, Severance Pay, Public Assistance Income, Child Support Payments, Military Compensation, Rental Property Income, Recurring Cash Contributions. 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 Code Section O.C.G.A. & 16-10-20-, and face criminal penalties as allowed by such criminal statute. *
