Dundee, NY · Yates County
Homeowners Workers’ Compensation Exemption Affidavit
This affidavit lets an owner of a one- to four-family, owner-occupied residence state why they are exempt from providing workers’ compensation coverage proof for work covered by 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
This one-page affidavit is for a homeowner applying for a building permit for a one- to four-family, owner-occupied residence. The owner checks the applicable reason they are not required to provide specific proof of workers’ compensation coverage, provides property and contact details, and swears to the statements before a notary. The form also describes coverage or proof obligations 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 with one to four families may use this form to claim an exemption from providing specific workers’ compensation coverage proof.
How to get this notarized
- 1
Download The Affidavit
Get the homeowners workers’ compensation exemption affidavit from the Dundee form source.
- 2
Complete The Form
Check the applicable exemption reason and enter the homeowner, contact, and property information.
- 3
Book An Online Notary
Schedule a session with a commissioned online notary and have identification ready.
- 4
Sign On Video
Sign and swear to the affidavit during the live video session before the notary.
- 5
Submit To The City
Provide the notarized affidavit to the government entity issuing your building permit.
Preview the form
The blank PDF straight from Dundee. 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 complete this homeowner exemption affidavit?
- Select the applicable exemption reason, fill in the homeowner and property details, then sign and swear to the affidavit before a commissioned online notary. Submit the notarized form with your building permit application.
- Do I need to sign the affidavit in front of a notary?
- Yes. The form includes a “Sworn to before me” jurat, so the homeowner must sign and swear to the statements before a notary completes the notary section.
- Can I notarize this form online?
- New York authorizes remote online notarization by a commissioned online notary under Executive Law §135-c. You can sign during a live video session and receive the completed notarized form.
- Where do I submit the notarized affidavit?
- The form says to provide it to the government entity issuing the building permit. Confirm with the city, town or village if unsure about submission instructions.
Homeowners 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.