Jenkintown, PA · Montgomery County
Workers’ Compensation Affidavit
This affidavit is for a permit applicant who states they will not hire anyone for the permitted project and must swear to that statement before a notary.
- 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
The affidavit records an applicant’s sworn statement that they will not employ or hire others for the project covered by a permit. If the applicant later hires anyone after receiving the permit, the form says they must notify the Borough office and provide proof of Workers’ Compensation coverage within three business days. The form warns that failure to comply may result in a stop-work order until proper coverage is obtained.
Who needs it
A person applying for a Borough permit who states they will not employ or hire anyone for the project must complete this affidavit.
Why it needs a notary
The form contains a sworn-and-subscribed jurat; the permit applicant signs and swears to the statement before the notary.
How to get this notarized
- 1
Download the Affidavit
Get the Workers’ Compensation Affidavit from the Borough’s form page.
- 2
Complete the Applicant Statement
Enter your information and review the statement about hiring workers for the permitted project.
- 3
Book an Online Notary
Schedule a remote session with a commissioned online notary.
- 4
Sign on Video
Sign and swear to the affidavit during the notary’s video session.
- 5
Submit It to the Borough
Send the completed, notarized affidavit to the Borough with your permit application.
Preview the form
The blank PDF straight from Jenkintown. 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 this affidavit notarized online?
- Complete the affidavit, then book a session with a commissioned online notary. Sign and swear to the statement during the video session, and submit the notarized form to the Borough.
- Do I need to sign this affidavit in front of a notary?
- Yes. The form includes a sworn-and-subscribed jurat, so the permit applicant must sign and swear to the statement before a notary.
- What must I do if I hire someone after receiving the permit?
- The affidavit says to notify the Borough office and provide proof of Workers’ Compensation coverage within three business days after hiring anyone for the project.
- Will the Borough accept an online-notarized affidavit?
- Pennsylvania permits its own commissioned notaries to perform remote online notarizations. Acceptance can depend on the Borough; confirm with the city, borough or township if unsure.
Workers’ Compensation Affidavit in other Pennsylvania cities
Each city publishes its own version of this form. Pick the city where you’re filing.