License Exemption Affidavit Form

LICENSE EXEMPTION AFFIDAVIT FORM

Affiant Name:   Trade or Business Name:

Business Address:

Telephone:   Email:

RECITALS

WHEREAS, Affiant states that Affiant conducts or will conduct activities described herein and seeks recognition that such activities are exempt from licensing requirements otherwise imposed by applicable licensing statutes, regulations, or local ordinances; and

WHEREAS, Affiant asserts that one or more statutory or regulatory exemptions apply to Affiant's operations and that this Affidavit will serve as the Affiant's sworn statement of the factual and legal basis supporting that claimed exemption; and

WHEREAS, the Licensing Authority requires a written sworn statement and supporting information to determine eligibility for exemption prior to issuing any notice of noncompliance or assessment of civil penalties;

NOW, THEREFORE

Affiant declares under penalty of perjury the following statements, representations, and certifications are true and correct to the best of Affiant's knowledge and that the Licensing Authority may rely upon this Affidavit in determining exemption status.

1. DEFINITIONS

For purposes of this Affidavit, the following definitions apply: "Affiant" means the person or entity identified above who executes this Affidavit; "Licensing Authority" means the governmental agency or official responsible for issuing the license or permit from which exemption is sought; "Exemption" means any statutory, regulatory, or administrative exclusion from licensing obligations.

2. BASIS FOR EXEMPTION (CHECK ALL THAT APPLY)

De minimis activity — the activity is incidental and insufficient in scope to require licensure.

Charitable or noncommercial purpose specifically exempted by statute or ordinance.

Interstate commerce exemption or federal preemption applies to the activity.

Temporary or incidental work performed pursuant to a limited-duration exception under applicable law.

Activity is expressly out of scope of the licensing statute or regulation.

Other (describe):

3. SUPPORTING FACTS

Describe with specificity the facts, circumstances, and any actions that form the basis for the claimed exemption. Include dates, locations, and names of persons or entities referenced. Attach copies of contracts, invoices, organizational documents, or other supporting records as indicated.

4. PERIOD OF EXEMPTION

Proposed Effective Date: Month Day Year

Proposed Expiration Date (if any): Month Day Year

5. REPRESENTATIONS AND WARRANTIES

Affiant represents and warrants that Affiant is authorized to submit this Affidavit on behalf of the named person or entity; that the facts stated herein are true, complete and correct; that Affiant will provide additional documentation upon request; and that Affiant will notify the Licensing Authority promptly if circumstances change such that the exemption basis is no longer accurate or applicable.

6. INDEMNIFICATION

Affiant agrees to defend, indemnify, and hold harmless the Licensing Authority and its officers, employees, and agents from and against any claims, liabilities, losses, or expenses (including reasonable attorneys' fees) arising out of or related to false statements, omissions, or misrepresentations made by Affiant in this Affidavit or in supporting documents.

7. NOTICES

8. AMENDMENTS, WAIVER, COUNTERPARTS

This Affidavit may be amended only by a written instrument signed by both Affiant and an authorized representative of the Licensing Authority. No waiver by either party of any provision of this Affidavit shall be effective unless in writing. This Affidavit may be executed in counterparts, each of which shall be deemed an original and all of which together constitute one instrument.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Affidavit shall be governed by and construed in accordance with the laws of the state in which the Licensing Authority is located without regard to choice-of-law principles. This Affidavit constitutes the entire agreement between the parties with respect to the subject matter hereof. If any provision of this Affidavit is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

ACKNOWLEDGMENT AND OATH

Affiant declares under penalty of perjury under the laws of the applicable jurisdiction that the foregoing is true and correct. Affiant understands that knowingly making a false statement in this Affidavit may subject Affiant to criminal prosecution and civil penalties.

If Affiant is signing on behalf of an entity, state the Affiant's capacity with the entity:

Sign Now