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AFFIDAVIT RELATIVE TO COMMERCIAL SOLID WASTE FEE EXEMPTION I, of being duly sworn, depose and say as follows: I (circle one) own or manage the property located Salem, MA (hereinafter the “Premises”) containing unit(s). I hereby state that the Premises is eligible for the exemption checked below: Private Solid Waste Collection Service/Self Disposal The Premises is serviced by a private solid waste collection company or I properly self dispose of the solid waste. I understand and acknowledge that I must notify the City in writing within five business days if this self disposal or the private contract is terminated. Unit Vacancy Unit # of the Premises is vacant or will be vacant as of 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. 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 this date of Owner/Manager Signature Daytime Phone Number For office use only Address: Account Number: Reason for Abatement: Original Trash Bill$ Bill Amount Abated$ Amount Due$