Form Wc 40 - Independent Contractor - Affidavit Of Exemption (Page 2 of 4) in pdf

Form Wc 40 - Independent Contractor - Affidavit Of Exemption Page 2

WC 40

GUIDELINES

The Independent Contractor must be doing residential construction to complete this affidavit.

An Independent Contractor with employees must have an active unemployment compensation

number. If the independent contractor is incorporated, t he officers will be considered employees.

If the Independent Contractor does not have an unemployment compensation number, an

application (SR-2) can be obtained from a local Unemployment Tax Office.

Once the Independent Contractor has completed the SR-2 form, the original goes to the

Unemployment Compensation Office and a copy is attached to the WC40.

Applications submitted to this office must be in blue or black ink.

Only an original affidavit will be processed. If the affidavit is submitted with any “copied” or

“faxed” pages, the affidavit will be denied.

Only WC40 forms issued by the Department of Industrial Relations, Workers’ Compensation

Division will be accepted.

The effective date of the affidavit will be the date it is first received in the Workers’ Compensation

Division. Affidavits will not be back dated.

All pages of the affidavit must be submitted in order for it to be considered for approval.

You may make copies of a blank affidavit if it is a clear copy without black lines or blurred

sentences.

BE SURE THAT:

The Independent Contractor signs, dates and give his title at the bottom of the affidavit.

The affidavit is notarized and appropriate notary seal is affixed. DO NOT place the notary seal

on the bottom portion of the affidavit.

The name, address and telephone number must be accurate for the Independent Contractor. NO

ABBREVIATIONS.

We must be able to read this information in order to mail the information

to concerned parties. YOU MUST PRINT THIS INFORMATION.

You will be notified if the affidavit is approved or denied. If approved, you will receive a

laminated card to present to resident ial builders. The card will be effective for one year and will

show the date to be renewed.

ALL QUESTIONS SHOULD BE DIRECTED TO SANDY HALLMARK

800-528-5166

Form Wc 40 - Independent Contractor - Affidavit Of Exemption Page 2