APPLICATION FOR ELECTRIC SERVICE DISCOUNT

FOR TOTAL PERMANENT DISABLED PERSONS

NAME ___________________________________________________________________

ADDRESS ________________________________________________________________

DATE OF BIRTH _________________       SOCIAL SECURITY NUMBER __________________

AMOUNT OF HOUSEHOLD INCOME FROM ALL SOURCES FOR YEAR ENDING

DECEMBER 31 _____________________

DO YOU OCCUPY AND RESIDE IN THE RESIDENCE OR HOMESTEAD?_______

DO YOU OWN OR RENT YOUR RESIDENCE?_______________________________

DOES YOUR SPOUSE RESIDE OR OCCUPY THE RESIDENCE WITH YOU?_____

HOW MANY OTHER PEOPLE RESIDE IN THE RESIDENCE WITH YOU?________

AFFIDAVIT OF CLAIMANT

I, the undersigned claimant, do solemnly swear that the above statements made in support of this application are true and correct, and that I am the bona fide resident for the above listed address for which this discount is being claimed, and that I actually occupied the same as my residence on January 1 of the year for which the discount is claimed. I am totally permanently disabled (must provide documentation), and the gross income for the entire household, including my spouse and any other persons residing in the household, for the preceding year did not exceed $15,000, and that no transaction has been made in collusion with another person for the purpose of obtaining this discount.  I further agree that any false statements, made herein, will cause me to surrender any previous discounts I have received. Claimant makes the above representations realizing that said representations will be relied upon by the City of LaFayette in my receiving any discount, and all false statements made by me herein may subject me to civil and criminal prosecution.

_____________________________                       ____________________________

Signature of Claimant                                               Date

________________________                                 ____________________________

City Clerk                                                                  Date

Sworn to and subscribed before me this_________day of_____________________, ____________.

_________________________________________                          __________________County, Georgia

Notary Public

My Commission expires ____________________,_________.

SEAL