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Snow Removal Assistance Program Information Dear Applicant, Thank you for your inquiry regarding the Butte-Silver Bow 2014-2015 Snow Removal Assistance Program. This program offers assistance with removing snow from sidewalks within the public right-of- way. This service applies to qualified resident of Butte-Silver Bow that are at least 65 years of age or have a certified medical need or disability AND fall under the financial guidelines. In order to be considered for this service, the applicant must be an: ●Individual who lives in a private, single family, residential property; ●Individual that is at least 65 years old OR and individual that has a certified medical need or disability(valid mobility handicapped parking permit, written verification of disability provided by Social Security Administration); ●Individual’s gross annual income is at or below one hundred fifty percent of the federal poverty level as published for the most recent year by the Unites States Department of Health and Human Services. Please complete the following documents and return them by mail or in person to Butte-Silver Bow Public Works Department, Attn: Leena, 126 West Granite Street, Butte, MT 59701. Public Works office hours are 8:00a.m. to 5:00 p.m., Monday through Friday. 1. Resident Application Form 2. Proof of Age (i.e. copy of Driver’s License) 3. Proof of Disability (i.e. Valid mobility handicapped parking permit, written verification of disability provided by Social Security Administration) 4. Proof of annual income (i.e. Tax return, the last two pay checks/income checks received) 5. Signed copy of Guidelines. Please allow for up to two weeks for the application to be reviewed and processed. Your approval/denial status will be sent out via mail. If you have any questions regarding this process, please call the Department of Public Works at 406-497- 6515. ---PAGE BREAK--- APPLICATION: SNOW REMOVAL EXEMPTION AND WAIVER OF LIABILITY The undersigned requests exemption to Butte-Silver Bow's snow removal ordinance. By signing this document, the undersigned affirms under penalties for perjury that all information contained in this application is true and accurate. The undersigned further acknowledges that furnishing false or misleading information to a government agency is a criminal offense. Documents showing proof of disability must accompany this application – Social Security disability determination. Full Name of Person Seeking Exemption Hereafter "Applicant" Last Name First Name Middle Name Property Address Where Applicant Resides (Include Zip Code): Address Street City State Zip Code Applicant's Phone Number: Applicant's Date of Birth: Owner of Property Where Applicant Resides and Applicant's Relationship to Property Owner: Property Owner's Name Relationship to Applicant Names and Ages of All Other Persons Living in Applicant's Home Property. Circle the Name Of Any Disabled Household Member. REASON FOR EXEMPTION/ Identify Disability and Diagnosis Of Disability. Explain How It Impairs Ability to Remove Snow. ---PAGE BREAK--- Check All That Apply: I receive Social Security Disability benefits (You must provide proof by a copy of Disability Determination or other valid document) I have been issued a valid mobility handicapped parking permit and I have a medical impairment that prevents me from shoveling snow. (Must provide proof of current handicapped license plate or hang tag from Bureau of Motor Vehicles.) I am over the age of 65 and my gross annual income is at or below one hundred fifty percent of the federal poverty level as published for the most recent year by the Unites States Department of Health and Human Services. No other person in my household can shovel or remove snow from my sidewalk, and I do not have any other person who can assist me. This application is not a guarantee of snow removal assistance. The Snow Removal Volunteer program is subject to availability of volunteers. Date: Signature Printed Name FOR AGENCY COMPLETION Reviewed by: Date: Approved: Disapproved: Reason for Disapproval: If further information is needed, identify: ---PAGE BREAK--- SIGNATURE AND RELEASE OF ALL LIABILITY As a condition of any snow removal assistance (the "Activity") I may receive from the Butte- Silver Bow, I hereby recognize and acknowledge that any volunteer snow shoveler performing the Activity is not an agent, servant, or employee of Butte-Silver Bow. The Volunteer is not performing the Activity at the behest of, or under the control or supervision of the Butte-Silver Bow, but rather at my request of and under my exclusive control and direction. Therefore, I agree that any claims or suits that I might pursue against the Volunteer as a result of my participation in the Activity specified herein, including but not limited to, claims of property damage, personal injury, and intentional tort, are my sole responsibility. I release the Butte-Silver Bow, its Departments, and its officers, employees, attorneys, and agents from any judgments, payments, damages and claims, including all costs, expenses and attorneys' fees incurred by me in pursuing any such claim. I further release the Butte-Silver Bow, all its Departments, and its officers, employees, attorneys, and agents, from any liability whatsoever for any and all acts or omissions of the Volunteer, under any theory of vicarious liability or otherwise. I further agree to assume the full risk of any property damage or personal injuries which I may sustain as a result of participating in the Activity. I hereby waive, release and discharge any and all claims for property damage and personal injury, including death, which I may have, or which may hereafter accrue to me, as a result of my participation in the Activity. I agree to indemnify and to hold harmless the City, its Departments, and its officers, employees, attorneys, and agents from any loss, liability, damage, cost, or expense which they may incur as a result of my death, injury, or property damage that I sustain, while participating in the Activity. This waiver, release and assumption of risk is binding upon my heirs and assigns. I further agree that if any claim or suit is pursued by me or on my behalf as a result of injuries from the Activity specified herein against the Butte-Silver Bow, its Departments, and its officers, employees, attorneys, and agents, I will indemnify and hold harmless these parties from all judgments, payments, damages and claims, including all costs, expenses and attorneys' fees incurred by these parties in defending against such claim. I HAVE CAREFULLY READ THIS WAIVER AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY, AND A CONTRACT BETWEEN THE BUTTE-SILVER BOW BEND AND ME, AND I SIGN IT OF MY FREE WILL. I FURTHER AFFIRM UNDER PENALTIES FOR PERJURY THAT ALL THE INFORMATION CONTAINED IN THE APPLICATION FOR EXEMPTION IS TRUE AND ACCURATE. Date: Signature Printed Name ---PAGE BREAK--- SNOW REMOVAL SERVICE INFORMATION AND GUIDELINES ELIGIBILITY & FEES: ● All residents living in the home must certify that they are at least 65 year of age or older. Proof of age and residency are required. ● The person(s) under age 65 residing at the home must be unable to assist with snow removal due to physical or mental impairment. A statement from the Social Security Administration or a Valid mobility handicapped parking permit must be provided annually. ● The person(s) gross annual income is at or below one hundred fifty percent of the federal poverty level as published for the most recent year by the Unites States Department of Health and Human Services. GENERAL INFORMATION: ● This service is provided, in accordance with Municipal Code 12.12.055. ● This service consists of removing snow from the property that lies within the public right-of- way. Butte-Silver Bow is not responsible for clearing your drive-way or sidewalks/walkways that are not in the public right-of-way. ● Snow removal will occurs within 24 hours of snow accumulation. ● If snow removal has not occurred within 24 hours of the end of the last snowfall, please call the Public Works office . Please sign and date below to confirm that you have read the program guidelines. Date: Signature Printed Name If you have any questions regarding the new snow removal laws or the volunteer assistance program, please call the Department of Public Works at [PHONE REDACTED].