Pawling, NY · Dutchess County
Affidavit of Exemption
Homeowners of one- to four-family, owner-occupied residences use this affidavit to explain why they are exempt from showing workers’ compensation coverage for building permit work.
What this form is
This affidavit lets the owner of a one- to four-family, owner-occupied residence, including a condominium, state why they are not required to show specific proof of workers’ compensation coverage for work covered by a building permit. The owner checks the applicable reason, certifies the statement under penalty of perjury, and agrees to provide coverage proof or an exemption form if the stated work conditions require it.
Who needs it
A homeowner applying for a building permit for a one- to four-family, owner-occupied residence may use this affidavit to state why coverage proof is not required.
How to submit it
Provide the completed affidavit to the government entity issuing the building permit.
About notarization
This document is signed without a notary; the signer certifies the statements under penalty of perjury and signs and dates the affidavit.
How to submit this form
- 1
Download The Affidavit
Download the Affidavit of Exemption PDF.
- 2
Complete The Affidavit
Check the applicable reason, enter the requested homeowner and property information, then sign and date the affidavit.
- 3
Review The Coverage Statement
Read the agreement about providing workers’ compensation coverage proof or an exemption form if the stated work conditions require it.
- 4
Submit With The Permit
Provide the affidavit to the government entity issuing the building permit.
Frequently asked questions
- Do I need a notary for the Affidavit of Exemption?
- No. This document is signed without a notary; the homeowner certifies the statements under penalty of perjury and signs and dates the affidavit.
- Who can use this Affidavit of Exemption?
- It is for the owner of a one- to four-family, owner-occupied residence, including a condominium, listed on the building permit being applied for.
- What does the affidavit ask the homeowner to certify?
- The homeowner selects the applicable reason for not showing workers’ compensation coverage proof and certifies the statement under penalty of perjury.
- How do I submit the Affidavit of Exemption?
- Provide the completed affidavit to the government entity issuing the building permit.
Need something notarized?
This Affidavit of Exemption doesn’t need a notary — but if you have another Pawling form that does, a commissioned online notary can help.