Greenwood Lake, NY · Orange County
Affidavit of Exemption for Workers’ Compensation
Homeowners applying for a building permit use this affidavit to state why they are exempt from showing workers’ compensation insurance coverage for an eligible residence.
What this form is
This affidavit is for an owner applying for a building permit for a one- to four-family, owner-occupied residence, including a condominium. It asks the homeowner to identify the reason they do not need to show workers’ compensation coverage and agree to provide coverage or exemption proof if the project’s paid work reaches the stated threshold. It also requests the homeowner’s signature, date, name, telephone number, and property address.
Who needs it
An owner applying for a building permit for an owner-occupied residence with one to four families may use this affidavit to explain the claimed 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; the signer just signs and dates it.
How to submit this form
- 1
Download the Affidavit
Download the Workers’ Compensation Exemption Affidavit for an eligible owner-occupied residence.
- 2
Complete the Affidavit
Check the applicable exemption reason and provide the requested homeowner and property information.
- 3
Review Your Commitment
Read the statement about providing workers’ compensation coverage or exemption proof if the project meets the stated work-hour threshold.
- 4
Sign and Submit
Sign and date the affidavit, then submit it to the city department named on the form.
Frequently asked questions
- Do I need a notary for the Workers’ Compensation Exemption Affidavit?
- No. This document is signed without a notary; the signer just signs and dates it.
- Who can use this affidavit?
- It is for an owner applying for a building permit for a one- to four-family, owner-occupied residence, including a condominium.
- What does the affidavit ask me to provide?
- It asks you to check the reason you are not required to show workers’ compensation coverage, agree to provide coverage or exemption proof if needed, and provide your signature, date, contact number, name, and property address.
- 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 Affidavit of Exemption for Workers’ Compensation doesn’t need a notary — but if you have another Greenwood Lake form that does, a commissioned online notary can help.