Tuckahoe, NY · Westchester County
Affidavit of Exemption to Provide Workers Compensation
This affidavit lets an owner of an owner-occupied one- to four-family residence certify an exemption from showing workers’ compensation coverage for a building permit.
What this form is
This affidavit is for an owner applying for a building permit for an owner-occupied one-, two-, three-, or four-family residence, including a condominium. It asks the homeowner to certify why specific workers’ compensation proof is not required, select the applicable statement about who performs or is paid for the work, provide property and contact details, and sign and date.
Who needs it
A homeowner applying for a building permit for an owner-occupied one- to four-family residence who is claiming an exemption from showing specific workers’ compensation proof needs this affidavit.
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 just signs and dates the affidavit.
How to submit this form
- 1
Download The Affidavit
Download the Workers Compensation Exemption Affidavit.
- 2
Complete The Affidavit
Select the applicable statement, enter the property and homeowner details, and sign and date the affidavit.
- 3
Gather The Building Permit
The affidavit refers to the building permit for the property; have that permit information available.
- 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 the Workers Compensation Exemption Affidavit?
- No. The homeowner signs and dates this affidavit without a notary.
- Who can use this affidavit?
- It is for an owner applying for a building permit for an owner-occupied one-, two-, three-, or four-family residence, including a condominium.
- What information does the affidavit ask for?
- The homeowner selects the applicable exemption statement and provides the property address, home telephone number, printed name, signature, and date.
- 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 to Provide Workers Compensation doesn’t need a notary — but if you have another Tuckahoe form that does, a commissioned online notary can help.