Adopted 1/1/97 AFFIDAVIT OF EXEMPTION FROM THE KENTUCKY WORKERS’ COMPENSATION ACT (Individual) Applicant, pursuant to KRS 342. 610 (5), hereby declares exemption from the requirement to obtain workers’ compensation insurance coverage as set forth in KRS 342.340. In support of this claim to exemption, Applicant states that the following facts are true and correct: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Full name of Applicant ____________________________________________________ Home address _______________________________ Phone No. ___________________ __________________________________________________________________ FEIN or SSN ______________________ Average No. of Employees________________ The foregoing is true and correct as I verily believe and swear. __________________________________________ Applicant/or authorized agent State of Kentucky Labor Cabinet County of _______________________ The foregoing Affidavit of Exemption was acknowledged and sworn to before me by _________________________, this ______ day of ___________________, 20___. __________________________________________ NOTARY PUBLIC KENTUCKY STATE AT LARGE MY COMMISSION EXPIRES_______________, 20___. Instructions This original Affidavit is to be immediately filed by the local building permit office with the Kentucky Department of Workers’ Claims, Divis ion of Security & Compliance, 657 Chamberlin Ave., Frankfort, KY 40601 (1-800-554-8601). A copy of this Affidavit is to be kept on file with the local office, which issues the building permit. Notice of Affiant: Fraudulent execution of this form constitutes a criminal offense (KRS 523.030), under the laws of the Commonwealth. American LegalNet, Inc. www.USCourtForms.com American LegalNet, Inc. www.USCourtForms.com