Application Form For Certificate Of Attestation Of Exemption (Page 4 of 4) in pdf

8. Please select the reason that the legal entity is NOT required to obtain New York State

Statutory Disability Benefits Insurance Coverage:

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A. The applicant is NOT applying for a disability benefits exemption and will show a separate certificate of NYS

statutory disability benefits insurance coverage.

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B. The business MUST be either: 1) owned by one individual; OR 2) is a partnership (including LLC, LLP,

PLLP, RLLP, or LP) under the laws of New York State and is not a corporation; OR 3) is a one or two person

owned corporation, with those individuals owning all of the stock and holding all offices of the corporation (in a two

person owned corporation each individual must be an officer and own at least one share of stock); OR 4) 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.)

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C. The applicant is a political subdivision that is legally exempt from providing statutory disability benefits

coverage.

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D. The applicant is a nonprofit (under IRS rules) with NO compensated individuals providing services except for

clergy; or is a religious, charitable or educational nonprofit (Section 501(c)(3) under the IRS tax code) with no

compensated individuals providing services except for executive officers, clergy, sextons, teachers or professionals.

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E. The business is a farm and all employees are farm laborers.

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F. 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.)

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G. 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

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 (in a two person owned corporation, each individual must be an officer and

own at least one share of stock). A Temporary Service Agency is a business that is classified as a temporary service

agency under the business’s North American Industrial Classification System (NAICS) code.

9. I affirm that due to my position with the above-named business I have the knowledge,

information and legal authority to make this Application for Certificate of Attestation of

Exemption. I hereby affirm that the information provided above is true and that I have not

submitted any materially false statements and I make this application for a Certificate of

Attestation of Exemption under the penalties of perjury. I further affirm that I understand

that any false statement, representation, or concealment will subject me to felony

prosecution, including jail and civil liability in accordance with the Workers’

Compensation Law and all other New York State Laws.

Signature

Title

Date

CE-200APPLY (2/2009)

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Application Form For Certificate Of Attestation Of Exemption Page 4

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