Who can use this affidavit?

An owner of an owner-occupied one-, two-, three- or four-family residence, including a condominium, applying for a building permit may use it.

What does the affidavit ask the homeowner to certify?

The homeowner checks an applicable reason for not showing specific proof of workers’ compensation coverage and provides property and contact details.

Forestport, NY · Oneida County

No notary required

Workers’ Compensation Exemption Affidavit for Owner-Occupied Residences

Homeowners applying for a building permit for an owner-occupied one- to four-family residence use this affidavit to certify an exemption from specific workers’ compensation proof.

What this form is

This affidavit lets an owner of an owner-occupied one- to four-family residence, including a condominium, certify why specific proof of workers’ compensation coverage is not required for the building permit. The homeowner checks the applicable reason, provides property and contact details, and signs and dates the form. It also states what coverage or exemption proof may be needed if paid work reaches 40 hours or more per week.

Who needs it

A homeowner applying for a building permit for an owner-occupied one- to four-family residence may use this affidavit to certify an eligible exemption.

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 without a notary; it contains a statement under penalty of perjury, and the signer signs and dates it.

How to submit this form

1
Download the Affidavit
Download the workers’ compensation exemption affidavit for an owner-occupied residence.
2
Complete the Form
Check the applicable reason and enter the property address, homeowner’s name, and telephone number.
3
Sign and Date
The homeowner signs and dates 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

Do I need a notary for this workers’ compensation exemption affidavit?: No. This document is signed without a notary. It contains a statement under penalty of perjury, and the signer signs and dates it.
Who can use this affidavit?: An owner of an owner-occupied one-, two-, three- or four-family residence, including a condominium, applying for a building permit may use it.
What does the affidavit ask the homeowner to certify?: The homeowner checks an applicable reason for not showing specific proof of workers’ compensation coverage and provides property and contact details.
How do I submit the affidavit?: Submit it to the city department named on the form; check the city website for current contact details.

Need something notarized?

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