CEP-24 5/2021
APPLICATION AND AFFIDAVIT FOR EXEMPTION
FROM SOLID WASTE COLLECTION FEES
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 collection of solid waste for the period
of _____________, 20_____ through______________, 20______.
4. I understand that under the terms of Code of Ala 1975, Section 22-27-3(a) (3):
The Local Health Officer is authorized to accept exemption requests and proofs 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 a 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 of my household 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 other income authorized by the Social Security Act, 42
U.S.C. 301 et seq.).
(c) Any unemployment compensation benefits, taxable disability benefits (other than SSI payments), or retirement benefits (other than
Social Security benefits), such as IRS or Keough 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 or any member of my household.
6. I 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, 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 first billing
date) each year, (b) that this exemption shall not become effective until approved in writing by a duly authorized officer of the local
governing body, (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 Print Name
Address ___________________________________ Phone Number_______________________________
City/State/Zip_______________________________ Billing Utility Co._____________________________
Sworn to and subscribed before me on this the ______ day of __________, 20______
________________________________________ _________________________
Notary Public My commission expires
…………………………………………………………………………………………………………………………………………
Exemption Granted: ____Yes ____No Date___________________________________
Signature of Duly Authorized Officer____________________________________________
