Please include a copy of proof of income by qob12941


									                                                      Peters Township
                                            Solid Waste & Recyclables Collection
                                              2009-2010 Discount Application
                                            Application Deadline: June 15, 2010
Name                                                     Date of Birth


Phone Number

Check here if spouse is deceased
Check here if you are on full disability*                      If yes, see comments below

Income Information:
Please include all income received by you, your spouse and any other permanent resident of your
household in 2009. Please include a copy of proof of income.

Social Security, SSI Payments & Railroad Retirement Benefits

Pension and Annuities

Interest, Dividends and Capital Gains

Rental Income

Net Business Income

Other Income Including Wages, Public Assistance,
Unemployment Benefits, Gifts, Lottery Winnings, Alimony,                   $
Spousal Support,Inheritance

Please Indicate:
My garbage is collected at the street curb

My garbage is collected at the rear of my house/garage

I am currently receiving the 10% senior discount

I declare that the information provided on this application is to the best of my knowledge true, correct and
complete and authorize Peters Township to verify my income through Peters Township Wage Tax Office
and the Commonwealth of Pennsylvania.
Print/Sign Name

 Submit by Email      Print Form
*For proof of disability you must submit a copy of award letter from Social Security or other appropriate
agency or from the Veterans Administration stating you are 100% disabled.

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