MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS Form 2 of 3 EMPLOYEE'S AFFIDAVIT AND WAIVER OF WORKERS' COMPENSATION BENEFITS TO BE FILED WITH THE §287.804 ­ Application for Religious Exception Name of Employee (Last, First, MI) Mailing Address ­ Street City County State SSN Date of Birth (MM/DD/YYYY) Phone Number (If Any) ZIP Code (9-Digit) Before me, the undersigned authority, personally appeared sworn on this oath states as follows: who, being duly (Name of Employee) My name is . I am of sound mind, capable of making this affidavit and wavier, and personally acquainted with the facts herein stated. If the employee is a minor, the parent or guardian by signing the application, states that he/she has explained the waiver of workers' compensation benefits to the minor. I do hereby state that I am a member of (Name of recognized religious sect or division) . Its established tenets and/or teachings conscientiously oppose member acceptance of any private or public insurance benefits which makes payments in the event of death, disability, old age, retirement or towards the cost of medical bills and provision of services for medical bills (including the benefits of any insurance system established by the Federal Social Security Act, 42 U.S.C. 301 to 42 U.S.C. 1397jj), and I adhere to said tenets and/or teachings. I am, therefore, knowingly and voluntarily waiving my rights to any benefits under the Missouri Workers' Compensation Law, Chapter 287, RSMo. I understand and agree that no medical treatment, compensation and death benefits or payments of any kind under Chapter 287, RSMo, will be provided to me in the event of a work-related accident, injury or occupational disease. I understand that an exception granted to me shall be valid until I rescind my election to reject benefits under the workers' compensation law or the religious sect or division that I am a member of ceases to meet the requirements of §287.804(1) RSMo. I understand that providing false and fraudulent information on this affidavit and waiver would be subject to investigation by the Division's Fraud & Noncompliance Unit and possible prosecution pursuant to §287.128 RSMo or other applicable laws. STATE OF MISSOURI COUNTY OF ) ) ) Signature of Employee and Date (Or Parent or Guardian in Case of Minor) Subscribed and sworn/affirmed to before me this day of My Commission Expires: , 20 . Relationship to Minor Notary Public (Notarial Seal) WC-138-3 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com