Free Employer's Affidavit for Religious Exception (WC-138-5) - Missouri

MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION

Form 3 of 3

EMPLOYER'S AFFIDAVIT OF EXCEPTION FROM WORKERS' COMPENSATION BENEFITS
TO BE FILED WITH THE §287.804 ­ Application for Religious Exception
Name of Employer Mailing Address ­ Street City County State Employer's Business Name Federal Employer Identification No. Phone Number Zip Code (9-Digit)

Before me, the undersigned authority, personally appeared sworn on this oath states as follows:

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

I am not

a construction industry employer. . Its established
(Name of recognized religious sect or division)

I do hereby state that I am a member of

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 Subscribed and affirmed to before me this day of My Commission Expires:

) ) )
Signature of Employer and Date

, 20

.

Notary Public

(Notarial Seal)

WC-138-5 (02-06) AI