New Windsor, NY · Orange County
Affidavit of Exemption to Show Specific Proof of Workers' Compensation Insurance
Homeowners use this affidavit to certify an exemption from showing workers' compensation insurance proof for a building permit on an owner-occupied residence.
What this form is
This affidavit lets an owner of a one- to four-family, owner-occupied residence, including a condominium, certify why workers' compensation insurance proof is not required for work covered by a building permit. It asks the homeowner to select the applicable exemption, provide a name, property address, telephone number, signature, and date, and describes coverage steps if paid work reaches 40 hours or more per week.
Who needs it
A homeowner applying for a building permit for a one- to four-family, owner-occupied residence may use this affidavit to certify an applicable 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 affidavit is signed without a notary; the homeowner certifies under penalty of perjury and signs and dates it.
How to submit this form
- 1
Download the Affidavit
Download the Workers' Compensation Exemption Affidavit PDF.
- 2
Complete the Form
Select the applicable exemption and enter the requested homeowner and property information.
- 3
Sign and Date
The homeowner signs and dates the affidavit, certifying its statements under penalty of perjury.
- 4
Submit to the City
Submit the affidavit 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 the Workers' Compensation Exemption Affidavit?
- No. The affidavit has a homeowner signature and date line, and the homeowner certifies under penalty of perjury; it does not require a notary.
- Who can use this affidavit?
- The form is for an owner of a one- to four-family, owner-occupied residence, including a condominium, listed on the building permit being applied for.
- What information does the affidavit ask for?
- It asks the homeowner to select an applicable exemption and provide a printed name, home telephone number, property address, signature, and date signed.
- How do I submit the affidavit?
- Submit it to the city department named on the form; check the city website for current contact details.