Macungie, PA · Lehigh County
Workers’ Compensation Information Form – Affidavit of Exemption
This notarized affidavit lets a property owner or contractor explain why workers’ compensation insurance is not required for work covered by a building permit.
At a glance
- Issued by
- City of Macungie · Macungie, Lehigh County, Pennsylvania
- Notarization
- Required: sign this form in front of a notary before filing it.
- Official source
- macungie.pa.us
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
- 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 form when applicable to Part C of the workers’ compensation form for a building permit. The signer indicates whether the property owner is doing the work, the contractor has no employees, or a religious exemption applies. The form also describes insurance responsibilities and, for a religious exemption, requires copies of exemption letters for all employees.
Who needs it
A property owner or contractor seeking to claim an exemption from workers’ compensation insurance for work under a building permit should complete this form when applicable to Part C.
Why it needs a notary
The form includes a subscribed-and-sworn jurat stating the signer appeared before the notary; the applicant must sign before a notary public.
How to get this notarized
- 1
Download the Form
Get the Workers’ Compensation Information Form and review the Affidavit of Exemption.
- 2
Complete the Applicable Section
Provide the property address, permit number, applicant details, and the exemption reason that applies.
- 3
Book an Online Notary
Arrange a session with a commissioned online notary and have identification ready.
- 4
Sign on Video
Sign the applicant section while appearing before the notary, who completes the jurat and seal.
- 5
Submit to the City
Submit the notarized form with your building permit materials; include religious exemption letters if applicable.
Preview the form
The blank PDF straight from Macungie. 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
- Who completes the Workers’ Compensation Affidavit of Exemption?
- The applicant, such as the property owner performing the work or a contractor claiming an exemption, completes the form when it applies to Part C of the workers’ compensation form.
- How do I submit the affidavit for a building permit?
- Complete the applicable exemption section, sign before a notary, and submit the notarized form with your building permit materials. Confirm the city’s submission instructions if you are unsure.
- Do I need to attach documents to this form?
- If claiming the religious exemption, the form says to attach copies of religious exemption letters for all employees. It does not list other required attachments.
- Can I sign this form with a commissioned online notary?
- Pennsylvania authorizes its notaries to perform remote online notarizations under 57 Pa.C.S. §306.1. Confirm with the city, borough or township if unsure whether it will accept this notarized form.