Get documents about "APPLICATION FOR SNOW REMOVAL SERVICES
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APPLICATION
Snowplow Assistance Program
(Please fully complete all three (3) pages)
This program will remain open to qualifying residents until it has reached its budgeted
capacity or February 26, 2010, whichever comes first.
Services may not begin for at least two (2) weeks after the complete application is received.
Note: All information on this Application and all information supplied with this Application is
a public record and is available for viewing by and/or copied to the general public.
As a resident of the City of Stow, I request participation in the Snowplow Assistance
Program for 2009-10.
STEP ONE (1): DISABILITY (If applicable)
Note: Attach a separate certificate for each disabled household member from a licensed
physician verifying this information. Go to Step 3.
Name: ________________________ □ I am totally and permanently disabled
Name: ________________________ □ I am totally and permanently disabled
Name: ________________________ □ I am totally and permanently disabled
STEP TWO (2): AGE OF HOUSEHOLD MEMBERS
List All Household Members & Birth Dates
Name: _______________________ Date of Birth: ______________________
Name: _______________________ Date of Birth: ______________________
Name: _______________________ Date of Birth: ______________________
Name: _______________________ Date of Birth: ______________________
Name: _______________________ Date of Birth: ______________________
Continued on Reverse Side
STEP THREE (3) – Income Criteria
Note: You do not have to complete this Step if all occupants of your household are age 75
years or older. Go to Step 4.
I have an annual combined gross income (includes all occupants of the home) of less than
the amount listed below according to the number of people living in the home, and have
attached a copy of all annual gross income statements for all individuals living at
this property.
(Check the appropriate box)
No. of Gross
Persons Income
□ 1 $21,100
□ 2 $24,100
□ 3 $27,150
□ 4 $30,150
□ 5 $32,550
STEP FOUR (4) – Miscellaneous Criteria
Note: You must be able to check all boxes.
□ There are no other able-bodied persons under the age of 65 residing in this house.
(Exceptions can be made only when a doctor provides a written excuse for the
person under 65 that he/she cannot shovel snow, which must be attached to this
Application).
□ I will reside in this house throughout the winter months (I am not a snowbird!).
□ This is not an apartment building or condominium.
□ My driveway is either concrete or asphalt and is not made of gravel, limestone, brick
or other similar surface.
□ I am not applying for “Apron Only” services.
STEP FIVE (5) – Garage Description
Note: Check the appropriate box.
□ I have a DETACHED garage OR □ I have an ATTACHED garage
Continued on Next Page
It is my understanding that the City of Stow will make a thorough investigation of all information
provided in connection with this Application. I authorize the City of Stow to verify any information
contained in this application and/or to obtain additional information as is necessary in order to
process my application. I, hereby, release the City of Stow, its agents and/or assigns from any
liability associated with the processing of my application.
I certify that, to the best of my knowledge and belief, the information given within this Application is
true and correct. I certify that I will be actively residing at this property and that there will be no
other able bodied individuals residing at this address who are capable of removing snow during the
period of this Program. Vacant homes and homes where the Applicant(s) have left for the
winter months are not eligible.
If this Application is approved by the City of Stow, I authorize the City of Stow, its officers,
employees, and contractors to come upon my premises (at the address indicated on this
application) for the purpose of plowing snow or related inspections. I further, forever, and
completely, hold harmless and release the City of Stow, its officers, agents, and employees from all
liability, claims, demands, damages, actions, and causes of action whatsoever which I might
otherwise have or enjoy as a result of the City of Stow providing the snowplowing services for
which I have applied.
I further understand that the Snowplow Assistance Program may be discontinued at any time by
the City of Stow and that there shall be no liability or claims arising to the City of Stow as a result of
the discontinuance of such program. I have received, read and will comply with the City of Stow’s
Rules & Regulations governing this Program. Additionally, I will comply with all applicable federal
and local requirements, policies, and administrative procedures.
WARNING
Ohio law, including but not limited to Ohio Revised Code Section 2921.13 Falsification, makes it a
criminal offense to make willful false statements or misrepresentations to the public officials
administering this program. Falsification is a Misdemeanor of the First Degree punishable by up to
180 days in jail and a fine of $1,000.
I attest that I meet all of the criteria stated and have attached the applicable information:
Signature
Printed Name
Address
Telephone Number
Please return or deliver this signed Application to:
City of Stow, Public Service Department
3760 Darrow Road, Stow, Ohio 44224
Phone: (330) 689-2829
The Public Service Department is located on the first floor of City Hall, in the West wing.
The office hours are 8:00 a.m. to 12:00 p.m. and 1:00 p.m. to 4:30 p.m., Monday through Friday.
