Do I need a notary for this affidavit?

No. The document has no notary block; the signer signs and dates it. It includes a certification under penalty of perjury.

What if paid work totals 40 hours or more per week?

The form says the homeowner may not file this affidavit and must instead obtain appropriate workers’ compensation coverage or have the general contractor provide proof of coverage or exemption.

Alexander, NY · Genesee County

No notary required

Workers’ Compensation Exemption Affidavit for Owner-Occupied Residences

This affidavit is for owners of one- to four-family, owner-occupied residences who seek a workers’ compensation exemption when applying for a building permit.

What this form is

Homeowners listed as the general contractor on a building permit may use this affidavit to claim an exemption for a qualifying owner-occupied residence. It asks the owner to select an applicable work or hiring situation and provide a signature, date, telephone number, printed name, and property address. The form describes other coverage requirements when paid work reaches 40 or more hours per week.

Who needs it

A homeowner listed as the general contractor on a building permit for a one- to four-family, owner-occupied residence may file this affidavit if an eligibility condition applies.

How to submit it

Submit it to the city department named on the form; check the city website for current contact details.

About notarization

This document is signed and dated without a notary; it includes a certification under penalty of perjury but lists no separate notarized attachment.

How to submit this form

1
Download The Form
Download the workers’ compensation exemption affidavit PDF.
2
Complete The Affidavit
Select the applicable work or hiring condition and fill in the requested homeowner and property details.
3
Sign And Date
Sign and date the affidavit.
4
Submit To The City
Submit it to the city department named on the form; check the city website for current contact details.

Frequently asked questions

Who can use this workers’ compensation exemption affidavit?: It is for a homeowner listed as the general contractor on a building permit for a one- to four-family, owner-occupied residence who meets one of the form’s stated conditions.
Do I need a notary for this affidavit?: No. The document has no notary block; the signer signs and dates it. It includes a certification under penalty of perjury.
How do I submit the affidavit?: Submit it to the city department named on the form; check the city website for current contact details.
What if paid work totals 40 hours or more per week?: The form says the homeowner may not file this affidavit and must instead obtain appropriate workers’ compensation coverage or have the general contractor provide proof of coverage or exemption.

Need something notarized?

This Workers’ Compensation Exemption Affidavit for Owner-Occupied Residences doesn’t need a notary — but if you have another Alexander form that does, a commissioned online notary can help.