Employers Affidavit for Religious Exception
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Employers Affidavit for Religious Exception Form. This is a Missouri form and can be use in Workers Comp.
Loading PDF...
Tags: Employers Affidavit for Religious Exception, WC-138-5, Missouri Workers Comp,
Form 3 of 3
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
EMPLOYER’S AFFIDAVIT OF EXCEPTION FROM WORKERS’ COMPENSATION BENEFITS
TO BE FILED WITH THE §287.804 – Application for Religious Exception
Name of Employer
Employer’s Business Name
Federal Employer Identification No.
Mailing Address – Street
Phone Number
City
County
State
Before me, the undersigned authority, personally appeared
sworn on this oath states as follows:
Zip Code (9-Digit)
who, being duly
(Name of Employer)
My name is
. I am of sound mind, capable of making this affidavit,
and personally acquainted with the facts herein stated.
I certify that I am the employer of
.
(Employee’s Name)
Check one:
I am not
I am
a construction industry employer.
I do hereby state that I am a member of
. Its established
(Name of recognized religious sect or division)
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 have reviewed this affidavit and to the best of my knowledge and belief, it is true and correct. I understand that
providing false and fraudulent information on this affidavit 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 Employer and Date
Subscribed and affirmed to before me this
day of
, 20
.
My Commission Expires:
Notary Public
(Notarial Seal)
WC-138-5 (02-06) AI
American LegalNet, Inc.
www.FormsWorkflow.com
