Haverstraw, NY · Rockland County
Workers’ Compensation Exemption Affidavit
Homeowners use this affidavit to certify why they are exempt from showing workers’ compensation insurance proof for work covered by a building permit.
What this form is
This affidavit is for an owner of a one- to four-family, owner-occupied residence who is applying for a building permit. It asks the homeowner to select the reason for exemption, certify the information under penalty of perjury, and provide a signature, date, telephone number, printed name, and property address. The form also describes coverage steps if paid work reaches 40 hours or more per week.
Who needs it
A homeowner applying for a building permit for an owner-occupied residence may use this form to certify a listed workers’ compensation 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 and dated without a notary; the signer completes the signature and date fields on the form.
How to submit this form
- 1
Download The Form
Download the Workers’ Compensation Exemption Affidavit.
- 2
Complete The Affidavit
Select the applicable exemption reason and complete the homeowner, signature, date, telephone, and property address fields.
- 3
Review The Coverage Steps
Review the form’s statements about coverage or exemption proof if paid work reaches 40 hours or more per week.
- 4
Submit To The City
Submit the completed form to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- What is the Workers’ Compensation Exemption Affidavit for?
- It lets a homeowner applying for a building permit certify a reason they are not required to show specific proof of workers’ compensation coverage.
- Who can complete this affidavit?
- The form is for the owner of a one- to four-family, owner-occupied residence, including a condominium, listed on the building permit.
- Do I need a notary for the Workers’ Compensation Exemption Affidavit?
- No. This document is signed and dated without a notary.
- How do I submit the Workers’ Compensation Exemption 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 doesn’t need a notary — but if you have another Haverstraw form that does, a commissioned online notary can help.