AFFIDAVIT OF EDC BENEFICIARY 
REGARDING RESIDENCY OF EMPLOYEES 
(29 V.I.C. Sec 710 (a)) 
Page 1 of ______ 
 
 
 
I hereby certify, under penalties of perjury, ________________________________________ an 
Economic Development Commission beneficiary, that the quarterly listing of the beneficiary employees and 
other information on pages ______ through ______ which are affixed and made part of this affidavit is a true 
and complete listing of such information for the quarter ending ______________________________________ 
*.  And further, that identification of employees residency conforms to 29 VIC Section 703(e) of which 
_____________ ( _________ %) are residents and _____________ ( ______ %) are non-residents; and in 
accordance with 29 VIC Section 708(h)  ______  employees are employed on a full time basis.   This report 
includes __________ new employees of whom ___________ were hired through the V.I. Department of Labor. 
 
 
CORPORATE OFFICIAL 
 
_______________________________________
Name (Print) 
 
_______________________________________
Signature 
 
_______________________________________
Title (only corporate officer, president, manager 
or person authorized to act in such a capacity.) 
 
_______________________________________
Date 
 
 
 
(SEAL)  
 
 
 
 
 
 
WITNESSES 
 
 
1.   
_______________________________________
Name (Print) 
 
     
_______________________________________ 
     Signature 
 
     
_______________________________________ 
     Mailing Address 
 
 
2. 
_______________________________________ 
     Name (Print) 
 
     
_______________________________________ 
     Signature 
 
     
_______________________________________ 
     Mailing Address 
 
 
 
(OR A NOTARY PUBLIC MAY BE USED INSTEAD OF TWO WITNESSES) 
 
 
SUBSCRIBED AND SWORN to before me this 
 
________ day of __________________,  
 
20________, 
 
 
 
 
 
______________________________________ 
Notary Public 
 
______________________________________ 
Name-Printed 
 
 
 
(SEAL) 
 
 
My Commission Expires 
 
 
* Affidavit with employee listing is to be submitted to the Economic Development Commission each quarter 
in conjunction with a copy of the V.I. Employment Security Agency’s “Employees Quarterly Wage and 
Contribution Report.”  
SIGN
SIGN
SIGN