REVISED 07/10/18
AFFIDAVIT AND APPLICATION FOR
EXEMPTION FROM
PAYMENT OF FEES
FOR COLLECTION AND DISPOSAL OF
SOLID WASTE
UNDER THE PROVISIONS OF
THE ALABAMA SOLID WASTE DISPOSAL ACT
STATE OF ALABAMA
COUNTY OF _____________________________
Before me, the undersigned Notary Public, personally appeared, ________________________________
who is known to me and who after first duly sworn deposes and says as follows:
1.
My name is _________________________________________________________.
2.
I reside at __________________________________________________________.
3.
I make this affidavit in aid of my application for an exemption from the payment of fees for solid waste
collection
for the period of _____________, 20____ through _____________, 20____.
4.
I understand that under the terms of Code of Ala. 1975, § 22-27-3(a) (2) and (3):
The Local Health Officer is authorized to accept exemption requests and proof
of income
from households seeking the exemption and to forward same to the
solid waste officer or
municipal governing body. The applicants shall verify
income through this notarized and
sworn statement and attach supporting documentation. The exemption shall apply only so
long
as
the household’s sole source of income is social security and shall be requested
no
later than the first billing date of each year in which the exemption is desired.
5.
I certify that neither I nor any person living in my home is receiving or eligible to receive:
(a) Any income from being employed in any capacity, or as a contractor, including part time employment or
contract work.
(b) Any income from any source whatsoever other than Social Security or SSI benefits.
(c) Any unemployment compensation benefits, taxable disability benefits (other than SSI payments), or
retirement benefits (other than Social Security benefits), such as IRS or Keogh Plans, from any source whatsoever.
(d) Any income from trusts or investments of any kind, including but not limited to income from savings
accounts, certificates of deposit, rental income, stocks, bonds, mortgages, mutual funds, investment plans, or
annuities.
(e) Any alimony payments for my benefits or the benefit of any member of my household.
6.
I further certify that in filing this application for exemption I understand that if it is later discovered that I or
any
persons living in my home are receiving any income in excess of Social Security or SSI
benefits, that I can be
charged with violating the laws, rules and regulations relating to the disposal of solid waste in_______________
County, Alabama, and thereafter compelled to pay all fees which I
would have otherwise been required to pay
during the period of my exemption.
7.
I further certify that I understand that:
(a) I must apply for this exemption annually before_____________(insert county billing date) each year,
(b) That this exemption shall not become effective
until approved in writing by a duly authorized officer of the
_________________________ County Solid Waste Disposal
Authority,
(c) That this application is being executed by me under oath as an inducement to grant me an exemption,
and
(d) That I may be called upon to produce other proof of my eligibility or continued eligibility for this exemption
at
any time either before or after the execution of this application.
SIGNED THIS THE _______ DAY OF ____________________ 20_____.
SIGNATURE OF APPLICANT/AFFIANT
ADDRESS: TELEPHONE #
SWORN TO AND SUBSCRIBED BEFORE ME ON THIS THE _____DAY OF _____________
,
20_____.
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
Exemption Granted: YES _____NO_____
SIGNATURE OF DULY AUTHORIZED OFFICER
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