VERIFICATION FORM FOR PHYSICALLY DISABLED PERSONS

RESIDENT'S STATEMENT FOR BACKYARD SANITATION COLLECTION SERVICES

(To be completed by resident requesting service.)

In accordance with the following physician's verification, I am physically unable to transport my household refuse to the curb for collection. I further verify that there is no able-bodied person residing or working at my residence who is capable of transporting my refuse to the curb for collection.

Resident's Signature

Date

Phone Number

PHYSICIAN'S STATEMENT

(To be completed by physician of requestee)

It is my professional opinion that __________________________________________________ is physically unable to transport his/her household refuse to the curb for collection.

Verification

It is my professional opinion that his/her disability is permanent.

It is my professional opinion that his/her disability is temporary. The temporary disability is anticipated to end _________________(Date).

Physician's Name

Physician's Signature

Physician's Phone Number

Physician's License #

It shall be unlawful for any person to willfully misrepresent information on this form. Aviolation of this section shall be a criminal misdemeanor subject to a penalty and/or imprisionment for each and every offense. The Solid Waste Services Department at all times has the authority to terminate such service upon a reasonable basis stated in writing to the recipient of the service. Upon termination of the service, the individual must immediately use the curbside rollout cart collection service.

This verification is valid until such time as re-verification may be required by City of Charlotte's Solid Waste Services Director.

UPON RECEIPT OF THIS VERIFICATION FORM, YOU WILL BE CONTACTED BY A SOLID WASTE SERVICES' TEAM MEMBER FOR AN ON-SITE INTERVIEW.

If you have any questions, please call 704.336.2673. Return this form by:

Mail
Solid Waste Services Department - Administration
1105 Otts Street
Charlotte, NC 28205

Fax
704.353.0330