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Application for SENIOR RATE Residential Solid Waste City of Cartersville Name: Address: Phone Number: Customer ID: Location ID: Application for Residential Solid Waste Senior Rate Exemption for persons 65 years of age or older. In accordance with City Ordinance #24-00, voted on and approved by the City Council in the June 15, 2000 regular meeting, I hereby make application for the exemption and in support thereof submit the following information: Date of Birth: Social Security Number: Physicians Statement as to Total Disability (attach copy) Documents used for age verification: Georgia Drivers License Birth Certificate Other I, the undersigned claimant, do solemnly swear that the above statements made in support of this application are true and correct, for which this exemption is claimed. I am 65 years of age or older. AFFIDAVIT OF CLAIMANT EFFECTIVE DATE CLAIMANT CITY CLERK OR AUTHORIZED OFFICAL 20