APPLICATION FOR SENIOR CITIZEN ELECTRIC SERVICE DISCOUNT

 

Name _____________________________________________________________________

Address ___________________________________________________________________

Date of birth _______________________     Social Security Number ____________________

Amount of household income from all sources for year ending December 31, 2005 $___________

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 claimed, and that I actually occupied the same as my residence on January 1 of the year for which this discount is claimed.  I am 70 year of age or older, 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 _______________________________.

 

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