Tuckahoe, NY · Westchester County
Workers’ Compensation Exemption Affidavit
This affidavit lets an eligible homeowner of a one- to four-family owner-occupied residence claim an exemption from showing workers’ compensation coverage when applying for a building permit.
- licensed online notary
- ~15 min average
- Notarized PDF emailed
What you’ll need
- Government-issued photo ID
- Webcam-enabled device (laptop or phone)
- This form, ready to upload as a PDF
What this form is
Tuckahoe building-permit applicants use this affidavit when they own and occupy a one- to four-family residence and meet one of the form’s listed conditions for exemption. The homeowner certifies the applicable condition, provides the property address, and signs under oath; the form also explains when paid work hours require coverage or other proof instead. Submit the notarized affidavit with the building permit application.
Who needs it
A homeowner applying for a building permit for an owner-occupied one- to four-family residence may need this affidavit if the form’s exemption conditions apply.
Why it needs a notary
The form has a “Sworn to before me” jurat; the homeowner signs the affidavit before a notary public, who completes the jurat.
How to get this notarized
- 1
Download the Form
Get the Workers’ Compensation Exemption Affidavit from the Tuckahoe document page.
- 2
Complete the Affidavit
Select the applicable exemption condition and enter the homeowner and property information.
- 3
Book an Online Notary
Schedule a remote session with a commissioned online notary.
- 4
- 5
Submit to the City
Send the notarized affidavit with your building permit application.
Preview the form
The blank PDF straight from Tuckahoe. Look it over, then upload your filled copy to start the notary session.
You’ll need ID and a webcam.
A licensed online notary will join you on video, verify your government-issued ID, witness your signature, and apply their seal. You’ll receive the notarized PDF by email when the session ends.
Frequently asked questions
- How do I get the Tuckahoe workers’ compensation affidavit notarized?
- Complete the form, then book an online notarization. Sign while a commissioned online notary watches by video, and submit the notarized affidavit with your building permit application.
- Do I need to sign this affidavit in front of a notary?
- Yes. The form includes a “Sworn to before me” jurat, so the homeowner must sign before a notary who completes the jurat.
- Can I use an online notary for this affidavit?
- New York authorizes remote online notarization by a commissioned online notary under Executive Law §135-c, in effect since 2023. Confirm with the city, town or village if unsure.
- Who may use this exemption affidavit?
- The form is for homeowners of one- to four-family owner-occupied residences who meet a listed exemption condition. It says the affidavit cannot waive any party’s workers’ compensation rights or obligations.
Workers’ Compensation Exemption Affidavit in other New York cities
Each city publishes its own version of this form. Pick the city where you’re filing.