<html> <head> <title>Rule 47:03:10:0A Affidavit of Exempt Status.</title> <META NAME="Keywords" Content="Administrative Rules 47:03:10:0A"> <META NAME="Description" Content="Administrative Rules 47:03:10:0A Affidavit of Exempt Status."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; line-height:115%; font-size:11.0pt; font-family:"Calibri","sans-serif";} @page WordSection1 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><a name="_GoBack"></a><span style='font-size:12.0pt; 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text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>DEPARTMENT OF LABOR AND REGULATION</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>DIVISION OF INSURANCE</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>AFFIDAVIT OF EXEMPT STATUS</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>Chapter 47:03:10</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>APPENDIX A</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>SEE: &#167;&nbsp;47:03:10:01</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><b><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Source:</span></b><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'> 41 SDR 219, effective July 1, 2015.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><b><span style='font-size:12.0pt; font-family:"Times New Roman","serif"'>APPENDIX A</span></b></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>STATE OF SOUTH DAKOTA )</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; ) SS&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; AFFIDAVIT OF EXEMPT STATUS</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>COUNTY OF ______________ </span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>I state under oath as follows:</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:45.0pt;margin-bottom:.0001pt;text-align:justify;text-indent:-45.0pt; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 1.&nbsp;&nbsp;I, ______________________, operating as_____________________________________,&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Independent Contractor)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Independent Contractor's Business Name)</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; have agreed to provide services for ____________________ during calendar year _____.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (General Contractor)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; (Year)</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 2.&nbsp;&nbsp;I have read, signed, and attached the Exempt Status Fact Sheet and understand that an Independent Contractor is one who engages to perform certain services for another, according to his own manner and method, free from control and direction of the contractor in all matters connected with the performance of the service, except as to the result or product of the work.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 3.&nbsp;&nbsp;I understand that based upon the representations in this Affidavit of Exempt Status that I have signed, I am requesting that the Contractor identified above consider my business to be that of an independent contractor; that I am not an employee under the Workers' Compensation Act and the policy issued by ___________________________________.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp; General Contractor's Insurance Carrier</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 4.&nbsp;&nbsp;I am an independent contractor, not an employee of the contractor, and I do not want workers' compensation insurance.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 5.&nbsp;&nbsp;I am not an employer for the purposes of the Workers' Compensation Act.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 6.&nbsp;&nbsp;I have read, signed, and attached the Exempt Status Fact Sheet describing what an Independent Contractor is and the information provided is not the result of force, threats, coercion, compulsion, or duress.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 7.&nbsp;&nbsp;I understand that the execution of this affidavit shall establish a rebuttable presumption that I am not an employee for purposes of the Workers' Compensation Act.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 8.&nbsp;&nbsp;I understand that by signing this affidavit I will not be eligible for compensation under the South Dakota Workers' Compensation Law.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 9.&nbsp;&nbsp;I understand the execution of this affidavit does not affect the rights or coverage of any employee of the individual executing the affidavit.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 10.&nbsp;I understand that soliciting or providing false information on this affidavit with actual knowledge is a Class 2 misdemeanor.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_______________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Independent Contractor Signature&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_______________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _______________________________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Independent Contractor Name&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Title</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Subscribed and sworn to before me this ________ day of _____________, 20 _____.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>________________________________ </span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Notary Public- South Dakota</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Seal)</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>My commission expires:_____________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>________________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>General Contractor Signature&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>________________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _______________________________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>General Contractor Name&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Title</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Subscribed and sworn to before me this _________ day of _____________, 20 _____.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_________________________________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Notary Public-South Dakota</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Seal)</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>My commission expires:_____________.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;line-height: normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> </div> </body> </html>