9
City of Social Circle
Senior Citizen Discount Application
I, __________________________________________________, residing at
____________________________________________________________
in the City of Social Circle, apply for the Senior Citizen Discount offered by the City on
my garbage rate.
To qualify for this discount, I state under oath that the following is true and accurate to
the best of my knowledge:
1. I am sixty-two (62) years of age or older.
2. I am the head of household and that the utility service for the above address is in
my name.
Note
The information provided in this document is subject to audit and verification as
deemed necessary by the City of Social Circle. Applicant agrees to notify the City
immediately of any change in circumstance that make the applicant ineligible for the
senior citizen discount.
_____________________________________________
Customer signature Date
______________________________________________
Customer account number
Sworn and subscribed before me this _____day of ______________, 20____
______________________________________________
Notary signature
My commission expires___________________________
______________________________________________
City Representative Date
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signature
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