The Affidavit of Exemption Workers Compensation is a sworn statement issued by the Blount County Department of Development Services in Maryville, Tennessee. A person applying for a building permit signs it to say they are exempt from the proof of Worker's Compensation insurance required by T.C.A. §13-7-211. It is one of the building forms on the Blount County Government Forms & Applications page, next to the Building Permit Application. On this page you can fill out the form online on FillingPDF and download or print the completed PDF; the original is published by Blount County.
Last updated
What is Affidavit of Exemption Workers Compensation – Blount County, TN?
The Affidavit of Exemption Workers Compensation is a one-page sworn statement, headed "Under T.C.A. §13-7-211," in which a building permit applicant affirms an exemption from the requirement to show proof of Worker's Compensation insurance.
The form is printed on the letterhead of the Blount County Department of Development Services, 303 McGhee Street, Maryville, TN 37801. At the top it asks for the permit application's jobsite address and the permit number. The applicant swears and affirms that they are applying for a building permit from the Department of Building Safety of the Blount County Government and are exempt from the requirements of T.C.A. §13-7-211, then checks one of three reasons:
- A. The applicant is not required to obtain coverage under the Tennessee Worker's Compensation Law, T.C.A. §§ 50-6-104 through 106.
- B. The applicant is performing work on their own property in their own county of residence.
- C. The applicant is directly supervising work on their own property in their own county of residence.
The permit applicant signs and dates the form. It is not a tax document and it is not the permit itself. The Blount County Forms & Applications page lists it under Building, alongside the Building Permit Application, the Building Permit Extension and a separate Affidavit of Exemption Plumbing License, which is a different form.
Who needs to file Affidavit of Exemption Workers Compensation – Blount County, TN?
The form is for a person who is applying for a building permit from Blount County Government and who is exempt from the proof of Worker's Compensation insurance required by T.C.A. §13-7-211. The person who signs is the permit applicant. The form names three situations, and you check only one:
- You are not required to obtain coverage under the Tennessee Worker's Compensation Law, T.C.A. §§ 50-6-104 through 106 (box A).
- You are performing work on your own property in your own county of residence (box B).
- You are directly supervising work on your own property in your own county of residence (box C).
If none of the three statements is true for you, the affidavit does not fit your situation, because it covers only these reasons. The form says nothing about anyone signing for the applicant, so the permit applicant signs it personally. It also does not cover plumbing licenses: Blount County lists a separate Affidavit of Exemption Plumbing License on its Forms & Applications page.
When to file Affidavit of Exemption Workers Compensation – Blount County, TN
Complete the affidavit when you apply for a building permit and claim an exemption from the proof of Worker's Compensation insurance required by T.C.A. §13-7-211. The form says the signer is "applying for a building permit," and it has lines for the permit application's jobsite address and the permit number, so it belongs with that permit application. No separate due date, validity period or renewal rule is printed on it. Check with the Department of Development Services, at the phone number on the form, if you need to know when it must reach the office.
How to fill out Affidavit of Exemption Workers Compensation – Blount County, TN
Enter the jobsite address
At the top, write the jobsite address shown on your permit application.
Enter the permit number
Write the Permit Number on the line provided, if one has been assigned to your building permit application.
Read the sworn statement
The text states that you are applying for a building permit from the Department of Building Safety of the Blount County Government and are exempt from T.C.A. §13-7-211 (proof of Worker's Compensation insurance).
Check one reason
Mark only one: A (not required to obtain coverage under T.C.A. §§ 50-6-104 through 106), B (performing work on your own property in your own county of residence) or C (directly supervising work on your own property in your own county of residence).
Sign and date the affidavit
The permit applicant signs on the line marked Permit Applicant's Signature and enters the date.
Review and download the PDF
Check that the address, permit number, box and signature are complete. Download or print the completed PDF from FillingPDF and deliver it with your building permit application as described under How to submit.
How to submit Affidavit of Exemption Workers Compensation – Blount County, TN
The form prints no submission instructions of its own, so there is no channel to list from it. Because the signer is applying for a building permit and the form asks for the permit's jobsite address and permit number, the affidavit goes with the building permit application.
The letterhead gives the contact details of the issuing office:
- Address: Blount County Department of Development Services, 303 McGhee Street, Maryville, TN 37801.
- Phone: 865-681-9301.
- Fax: 865-681-9502.
The form does not say which of these the department accepts for the affidavit, so call before you send it. The Blount County Forms & Applications page, at https://www.blounttn.gov/1243/Forms-Applications, lists this affidavit with the other building forms, including the Building Permit Application. FillingPDF lets you fill out and download the PDF; submission follows the channels the county provides.
Common mistakes to avoid
- Checking more than one of boxes A, B and C; the form says to check one.
- Leaving all three boxes blank, so the affidavit does not state which exemption the applicant claims.
- Submitting the form without the permit applicant's signature and date.
- Checking box B or C for work on property that is not your own, or that is outside your own county of residence.
- Checking box A without being exempt from coverage under the Tennessee Worker's Compensation Law, T.C.A. §§ 50-6-104 through 106.
- Leaving out the jobsite address or permit number requested at the top of the form.
- Using this form for a plumbing license exemption; Blount County lists a separate Affidavit of Exemption Plumbing License.
Frequently asked questions
What is the Affidavit of Exemption Workers Compensation?
It is a one-page sworn statement from the Blount County Department of Development Services. A building permit applicant uses it to affirm an exemption from the proof of Worker's Compensation insurance required by T.C.A. §13-7-211, by checking one of three stated reasons.
Who can claim the exemption on this affidavit?
A building permit applicant who is not required to obtain coverage under T.C.A. §§ 50-6-104 through 106, or who is performing or directly supervising work on their own property in their own county of residence. Check only the one reason that applies.
Can I check more than one box on the affidavit?
No. The form says "Check one" above boxes A, B and C. Pick the single statement that matches your situation, then sign and date the form as the permit applicant.
Is this a Blount County property tax form?
No. The form concerns proof of Worker's Compensation insurance for a building permit and contains no property tax information. It is published among the building forms on the Blount County Forms & Applications page, not as a tax document.
Where do I turn in the Affidavit of Exemption Workers Compensation?
The form prints no submission channel. It goes with your building permit application to the Department of Development Services, 303 McGhee Street, Maryville, TN 37801. Call 865-681-9301 to confirm how the department accepts it.
Is there a deadline to file this affidavit?
The form prints no separate deadline. It is signed by someone applying for a building permit and asks for the jobsite address and permit number, so it is completed with the permit application.
Is this the same as the Affidavit of Exemption Plumbing License?
No. Blount County lists the Affidavit of Exemption Plumbing License as its own form on the Forms & Applications page. This affidavit covers only the exemption from proof of Worker's Compensation insurance under T.C.A. §13-7-211.
Can I fill out this affidavit online on FillingPDF?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service, not connected to Blount County, and it does not file or submit the affidavit; you deliver it through the county's channels.
Ready to fill out Affidavit of Exemption Workers Compensation – Blount County, TN?
Fill out Affidavit of Exemption Workers Compensation – Blount County, TN now