2. Customer Name*
4. Customer Service Address*
5. City, State, Zip*
7. Mailing Address (if different from Service Address)
8. City, State, Zip
10. Daytime Phone *
11. Email Address*
13. Daphne Utilities Account Number*
14. Last 4 Digits of Social Security #*
16. (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:

    1. My home is vacant & no solid waste is generated (attach proof of current residency)*
    2. I have a permit from the Health Department to dispose of my own household garabge at the landfill or have a commercial solid waste business account (attach copy of permit or copy of bill)
    3. Resident at above mentioned property is deceased & no garbage is generated (attach a copy of Death Certificate)
    4. I am disabled & there is no one in my household that is physically able to place my garbage curbside*

18. Please Note: If the only income for your household is from Social Security or S.S.I. (please list sources of total income & attach copy of current bank statement, social security benefits or tax form). please contact Daphne Public Works directly. at 251-620-2100.

20. * Explanation(s) from above
22. 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.
24. Resident Digital Signature*
25. Digital Signature Date*
    Digital Signature Date
27. 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)
29. Attachments Required*
    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.
31. OFFICIAL INTERNAL USE ONLY
33. Action Taken:

    1. Approved
    2. Denied
34. Date
    Date
36. Internal Notes:
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field