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Application for Exemption/Credit or Backdoor Service

  1. (Choose one or more options)
    I reside in the service area of the City of Daphne Public Works Solid Waste Collection. I hereby apply for an exemption from payment and/or backdoor service due to the following circumstances:
  2. Certification
    I hereby certify that the above information is true & correct to the best of my knowledge, and I hereby give permission to the City of Daphne to investigate any & all of the above information. I understand that any current and/or previous bills are due as specified by the due date on the bill, and, that if approved, the exemption will go into effect the same month that my application is received. In the event that a credit is requested, if approved, it will be applied to your account. Exemptions must be renewed each year by January 31.
  3. Notice
    It is a Class "C" felony to falsely complete a written instrument required by a public office. (Alabama Criminal Code 13-A-9-3)
  4. A copy of your drivers license and current Daphne Utilities bill is required with each application. A bank statement or tax form is required for income based exemptions. Additional information may be required to better consider your application.
  5. OFFICIAL INTERNAL USE ONLY
  6. Action Taken:
  7. Leave This Blank:

  8. This field is not part of the form submission.