Name of second child:
Birth Date:
I have attached a copy of identification for each child that states his/her name and birthdate.
Please note: once identification has been checked and verified, it will be destroyed immediately.
Terms and Conditions (please check each box, to confirm you have read and accept these terms and
conditions):
I acknowledge that this allowance is due to excess diapers only, due to two (2) or more infants/
children under the age of four (4) within the household that are in diapers.
Only diapers will be placed in the extra clear garbage bag/container, with the bag tag affixed.
The tags are for use by the above noted resident only, and cannot be transferred or re-sold. The
bag tags hold no cash value.
If the exemption is no longer required, I will notify the County and return any remaining tags.
I will notify the County if I move, and give the change in address.
I also acknowledge that participation in Dufferin County's Blue Box and Green Bin programs is
required under the Waste Services By-law, and agree to fully participate in these programs, if
approved for a diaper exemption.
I certify that the information provided is, to the best of my knowledge, correct and complete.
Signature (not required for email submission below):
Date:
Notice with Respect to the Collection of Personal Information
Personal information requested on this form is collected as a necessary part of the administration
of Waste Services by the County of Dufferin pursuant to its legal authority as set out in the
Municipal Act, 2001. Collection, use and confidentiality of the personal information will be
according to the standards of the Municipal Freedom of Information and Protection of Privacy
Act and the information will be used for the purpose of verification of eligibility for specialized
set out service programming only. Questions or concerns about collection, use or disclosure of
personal information should be directed to the Director of Public Works at 519-941-2816 ext.
2600.
