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OFFICE USE ONLY: □ License □ Bill: Date of Bill: □ Other: □ Initials: FY 2024 □ Owner Occupied □ Unit Vacancy AFFIDAVIT RELATIVE TO RESIDENTIAL SOLID WASTE FEE EXEMPTION I, of . Print name of owner/manager Mailing address if different than property address Being duly sworn, depose and say as follows: I (circle one) own or manage the property located at , Salem, MA 01970 (hereinafter the “Premises”) Property address location containing total # of unit(s) you own. The information set forth herein is true, to the best of my knowledge, information, and belief. Signed and sealed under the pains and penalties of perjury on the day of , 20 . Day Month Year Owner/Manager’s Signature Daytime Phone Number I HEREBY STATE THAT THE PREMISES IS ELIGIBLE FOR THE EXEMPTION CHECKED below: 1) OWNER-OCCUPIED EXEMPTION I reside as an owner-occupant at Premises and as a result the Premises is exempt from the solid waste collection fee. My interest in the Premises is established by: . (Deed, Trust, etc.) ***If you satisfy this exemption, please provide a copy of your driver’s license and current phone or cable bill to City Hall Annex, 98 Washington Street, Second Floor, Salem, MA 01970*** 2) UNIT VACANCY Unit # of the Premises is vacant or will be vacant as of . Specify unit Current date Please specify up to ONLY 3 months at a time, if known: (NOTE: A new affidavit is required for every 3 month period.) □ July 2023 □ August 2023 □ September 2023 □ October 2023 □ November 2023 □ December 2023 □ January 2024 □ February 2024 □ March 2024 □ April 2024 □ May 2024 □ June 2024 Therefore, I am requesting a waiver of the trash fee for Unit # . I understand and acknowledge that the City of Salem will not issue a waiver of trash fees for any month that PRECEDES THE DATE this affidavit is submitted to the City. Further, I acknowledge and understand that the City has the right to issue a fine equal to twice the amount of the single unit fee for any false representations made by any individual concerning the vacancy status of a residential unit, and that a new affidavit must be completed for each month the unit is vacant. OFFICE USE ADDRESS/REASON ACCOUNT NUMBER: ORIGINAL TRASH BILL _ BILL NUMBER: _ MONTH/YEAR: AMOUNT ABATED _ BILL NUMBER: _ MONTH/YEAR: AMOUNT DUE _ BILL NUMBER: _ MONTH/YEAR: