Wilmington, IL · Greene County
Affidavit of Exempt Status Under the Workers’ Compensation Act
This affidavit and fact sheet let an independent contractor declare exempt status and provide information for a contractor’s Wilmington contractor registration.
- licensed online notary
- ~15 min average
- Notarized PDF emailed
What you’ll need
- Government-issued photo ID
- Webcam-enabled device (laptop or phone)
- This form, ready to upload as a PDF
What this form is
The affidavit records an independent contractor’s statements about their work, insurance, and exempt status under the Workers’ Compensation Act; the attached fact sheet helps them assess whether the statements fit their situation. The form says it must be signed and notarized at the start of a job or project for the contractor. It is valid for that project or a similar project for the same contractor for one year from the notarization date.
Who needs it
An independent contractor completing Wilmington contractor registration should use this form at the start of a job or project for the contractor.
How to get this notarized
- 1
Download the Form
Get the affidavit and Exempt Status Fact Sheet from the City of Wilmington.
- 2
Review and Fill Out
Review the fact sheet and complete the affidavit with your business, contractor, project, and insurance information.
- 3
Book an Online Notary
Arrange an online notarization with a commissioned online notary.
- 4
Sign on Video
Sign the affidavit in the notary’s presence during your online video session.
- 5
Submit to the City
Submit the notarized form as part of your contractor registration.
Preview the form
The blank PDF straight from Wilmington. Look it over, then upload your filled copy to start the notary session.
You’ll need ID and a webcam.
A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.
Frequently asked questions
- How do I complete this affidavit?
- Review the attached fact sheet, complete the affidavit, and sign it before a notary. The form says to sign and notarize it at the start of the job or project.
- Do I need to sign in front of a notary?
- Yes. The form includes a signed-and-sworn jurat, so the independent contractor must sign before the notary, who completes the notarial block.
- Can I use an online notary for this form?
- Illinois authorizes its notaries to perform electronic and remote notarizations, and recognizes notarial acts performed outside Illinois by an officer authorized where the act occurs. Use a commissioned online notary and confirm with the city or village if unsure.
- How long is the affidavit valid?
- The form states that it is good for the job or project, or any similar job or project performed for the contractor, for one year from the date of notarization.