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Hardship Waiver City of Salem For Curbside Bulk Item Pick Up & Mattress and Box Spring Curbside Pick Up 1. Name: First Name Middle Name Last Name 2. Address: (Street and Number) (City/Town) (State and Zip) SECTION 1: I AM INDIGENT in that (check only one): A. ☐ I receive public assistance under (check form of public assistance received): ☐ Transitional Aid to Families with Dependent Children (TAFDC) ☐ Supplemental Security Income (SSI) ☐ Massachusetts Veterans Benefits Programs; OR Emergency Aid to Elderly, Disabled, or Children (EAEDC) ☐ Medicaid (MassHealth) B. ☐ I am unable to pay the fees and costs of this service, or I am unable to do so without depriving myself or my dependents of the necessities of life, including food, shelter, or clothing. SECTION 2: I request that the following fees for Curbside Bulk Item Pickup or Curbside Mattress and Box Spring Recycling services be waived. ☐ Curbside Bulk Item Pick Up ($20/item) ☐ Curbside Mattress/Box Spring Pick Up ($20/item) Total Amount Requested to be waived: Signature: Date of Signature MM DD YY Please return to Waste Reduction Coordinator Engineering Department 2nd Floor 98 Washington Street Salem MA 01970