Media, PA · Delaware County
Workmen's Compensation Affidavit
This affidavit is for a person seeking a Borough of Media building permit to swear they will not hire others for the project and to acknowledge later workers’ compensation obligations.
- 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
Use this affidavit when seeking a Borough of Media building permit. The applicant swears they will not hire anyone for the project. If they later employ others after receiving the permit, they must notify the Borough in writing and provide proof of workers’ compensation coverage within three days. The form warns that noncompliance may lead to a stop-work order that can remain in place until proper coverage is obtained.
Who needs it
A person seeking a Borough of Media building permit who will not hire other people for the project needs to complete this affidavit.
Why it needs a notary
The form has a subscribed-and-sworn jurat, so the building permit applicant signs and swears to the statement before the notary.
How to get this notarized
- 1
Download the Affidavit
Get the Workmen's Compensation Affidavit from the Borough of Media.
- 2
Review and Complete the Statement
Read the affidavit and complete the applicant information before your notary appointment.
- 3
Book an Online Notary
Schedule a remote appointment with a commissioned online notary.
- 4
Sign on Video
Sign and swear to the affidavit during the online notarization session.
- 5
Submit It to the Borough
Send the completed, notarized affidavit to the Borough of Media with your building permit materials.
Preview the form
The blank PDF straight from Media. 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 the Workmen's Compensation Affidavit?
- Fill in the affidavit, then sign and swear to its statement before a commissioned online notary. Submit the completed form to the Borough of Media as part of your building permit process.
- Do I need to sign this affidavit in front of a notary?
- Yes. The form includes a subscribed-and-sworn jurat and spaces for the applicant’s signature, the notary public’s signature, and the notary’s commission expiration.
- Can I use online notarization for this affidavit?
- Pennsylvania authorizes remote online notarization for its own notaries under 57 Pa.C.S. §306.1, effective since 2020. Arrange a remote appointment with a commissioned online notary and confirm the Borough will accept the notarized form.
- What if I hire someone after receiving my building permit?
- The affidavit says you must notify the Borough of Media in writing and provide proof of workers’ compensation coverage within three days. It warns that failure to comply may result in a stop-work order.
- Where do I submit the completed affidavit?
- The form is for a person seeking a Borough of Media building permit. Submit it to the Borough with your permit materials; confirm with the city, borough or township if unsure.