Angola, NY · Erie County
Workers’ Compensation Exemption Affidavit
This affidavit lets an owner of a one- to four-family owner-occupied residence explain why workers’ compensation coverage is not required when applying for a building permit.
- 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
This affidavit is for the owner of a one- to four-family owner-occupied residence, including a condominium, who is applying for a building permit and claims an exemption from showing workers’ compensation coverage. The homeowner checks the applicable reason, signs under penalty of perjury, and submits the form to the government entity issuing the permit; the form also describes when coverage or other proof is needed if paid work reaches 40 hours per week.
Who needs it
A homeowner listed as general contractor on a building permit may need this form when claiming an exemption for a qualifying owner-occupied residence.
How to get this notarized
- 1
Download the Affidavit
Get the Workers’ Compensation Exemption Affidavit from the village or permit office.
- 2
Complete the Form
Enter the homeowner and property information, then check the reason that applies.
- 3
Book an Online Notary
Schedule a remote session with a commissioned online notary.
- 4
Sign on Video
Show identification and sign and swear to the affidavit during the online notarization.
- 5
Submit to the City
Send the notarized affidavit with your building permit application as directed.
Preview the form
The blank PDF straight from Angola. 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 notarize this workers’ compensation exemption affidavit?
- Complete the applicable checkbox section, then sign and swear to the affidavit before a notary. Submit the notarized form with your building permit application as directed.
- Do I need to notarize the affidavit before filing it?
- The form includes a sworn-to jurat for the homeowner. The homeowner signs and swears to the statements before a notary.
- Can I sign the affidavit with a commissioned online notary?
- New York authorizes remote online notarization by its notaries under Executive Law §135-c, effective since 2023. Confirm with the city, town or village if unsure whether it will accept your remotely notarized form.
- When might this exemption affidavit not apply?
- The form says homeowners hiring or paying workers for 40 or more total hours per week may not file this affidavit and must provide appropriate coverage proof or have the general contractor provide proof.
Other forms in Angola
Workers’ Compensation Exemption Affidavit in other New York cities
Each city publishes its own version of this form. Pick the city where you’re filing.