Affidavit For New York Entities With No Employees And Certain Out Of Page 2

Download a blank fillable Affidavit For New York Entities With No Employees And Certain Out Of in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Affidavit For New York Entities With No Employees And Certain Out Of with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

4b.) the business is a LLC, LLP, PLLC, PLLP or a RLLP; OR is a partnership under the laws of New York State and is not a

corporation. Other than the partners or members, there are no employees, day labor, leased employees, borrowed employees, part-

time employees, unpaid volunteers (including family members) or subcontractors.

(Must attach separate sheet with a list of all the

partners/members names and also with the signatures of all the partners/members – Limited Partnerships must ONLY list General Partners.)

4c.) the business is a one person owned corporation, with that individual owning all of the stock and holding all offices of the

corporation. Other than the corporate owner, there are no employees, day labor, leased employees, borrowed employees, part-time

employees, unpaid volunteers (including family members) or subcontractors.

4d.) the business is a two person owned corporation, with those individuals owning all of the stock and holding all offices of the

corporation (each individual must own at least one share of stock). Other than the corporate owners, there are no employees, day

labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or

subcontractors.

(Must attach separate sheet with a list of the names of both owners, and also with both owners’ signatures.)

4e.) the applicant is a nonprofit entity (under IRS rules). With the exception of clergy or teachers, the nonprofit has no compensated

individuals providing any services including subcontractors.

4f.) the business is a farm with less than $1,200 in payroll the preceding calendar year.

4g.) the applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence. The homeowner

has no employees, day labor, leased employees, borrowed employees, part-time employees or subcontractors.

4h.) other than the business owner(s) and individuals obtained from a registered temporary service agency, there are no employees,

day labor, leased employees, borrowed employees, part-time employees, unpaid volunteers (including family members) or

subcontractors. Other than the business owner(s), all individuals providing services to the business are obtained from a registered

temporary service agency and that agency has covered these individuals for New York State workers' compensation insurance. In

addition, the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or

is a one or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation

4i.) the out-of-state entity has no NYS employees and/or NYS subcontractors AND ALL work related to the permit, license or

contract is done outside of NYS; OR ALL employees are direct employees of a government entity outside of New York (Applicant

MUST attach a certificate of insurance from its foreign or other State’s workers’ compensation insurance policy to this Affidavit).

5. That the above named business is certifying that it is NOT REQUIRED TO OBTAIN NEW YORK STATE DISABILITY

BENEFITS INSURANCE COVERAGE for the following reason (to be eligible for exemption, applicant must be able to truthfully

check ONE of the boxes from 5a. through 5f.):

5a.) the business is owned by one individual or is a partnership under the laws of New York State and is not a corporation; or is a one

or two person owned corporation, with those individuals owning all of the stock and holding all offices of the corporation or is a

business with no NYS location. In addition, the business does not require disability benefits coverage at this time since it has not

employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are not

considered to be employees under the Disability Benefits Law.)

5b.) the applicant is a political subdivision that is legally exempt from providing statutory disability benefits coverage.

5c.) the applicant is a nonprofit with NO compensated individuals providing services; or is a religious, charitable or educational

nonprofit with no compensated individuals providing services except for executive officers, clergy, sextons, teachers or professionals.

5d.) the business is a farm and all employees are farm laborers.

5e.) the applicant is a homeowner serving as the general contractor for his/her primary/secondary personal residence. The homeowner

has not employed one or more individuals on at least 30 days in any calendar year in New York State. (Independent contractors are

not considered to be employees under the Disability Benefits Law.)

5f.) other than the business owner(s) and individuals obtained from the temporary service agency, there are no other employees. Other

than the business owner(s), all individuals providing services to the business are obtained from a registered temporary service agency

and that agency has covered these individuals for New York State disability benefits insurance. In addition, the business is owned by

one individual or is a partnership under the laws of New York State and is not a corporation; or is a one or two person owned

corporation, with those individuals owning all of the stock and holding all offices of the corporation.

By signing my name below, I hereby affirm that the statements made herein are true, that I have not made any materially false statements and

I make this affidavit under the penalties of perjury. I further affirm that I understand that any false statement, representation or concealment will

subject me to felony criminal prosecution, including jail and civil liability in accordance with the Workers’ Compensation Law and all other New York

State laws. I also hereby affirm that if circumstances change so that workers’ compensation insurance and/or disability benefits coverage is required, the

above-named business will immediately acquire appropriate New York State specific workers’ compensation insurance and/or disability benefits coverage

and also immediately furnish proof of that coverage on forms approved by the Chair of the Workers’ Compensation Board to the government entity listed

in item 3 on the front of this form

_______________________________________________________

(Applicant’s Signature -- first and last name)

Sworn to before me this ____________

Day of _____________________, 20__

_______________________________

Notary Public

NYS Workers’ Compensation Board Received Stamp

WC/DB-100 (9-07) Reverse