2. I, the undersigned, declare under penalty of perjury, that I am a citizen of Blaine who qualifies for a reduced sewer charge as provided in Section Sec. 86-142 of the City Code, as amended.
   
   It is requested that the public utilities billing for the home at the location listed below reflect the appropriate reduced sewer rates.
4. Extracted from City Code Section Sec. 86-142:
   Section 86-142 - Reduced Sewer Service Charges.
   
   (1)Persons who are 62 years of age or older, or who are members of a household in which one of the spouses is 62 years of age or older, and neither is gainfully employed
   
   (2)Persons who are 62 years of age or older, or who are members of a household in which one of the spouses is 62 years of age or older, and neither is gainfully employed, who occupy the unit with not more than two other persons, who are also 62 years of age or older, or who occupy the unit with one person under 62 years of age, who is not gainfully employed
   
   (3)Persons who are 62 years of age or older, or who are members of a household in which one of the spouses is 62 years of age or older, and neither is gainfully employed, who occupy the unit with more than two other persons, one of whom is 62 years of age or older and head of the household, and the annual gross income of the household according to its most recent federal income tax return does not exceed the federal poverty income guidelines for a family of four, plus $3,000.00, and the total assets of the household, exclusive of the homestead, do not exceed $20,000.00. If no federal income tax return was filed, the applicant shall be required to submit other documentation to show that this qualification is met.
   
   (b)Such reduced quarterly charge shall be effective in the first billing quarter that commences following receipt of the appropriate city application forms, completed by the individual persons over 62 years of age. Such reduced quarterly charge shall become effective in the first billing quarter after there has been a change in the conditions described in subsection (a) of this section. Persons meeting such requirements shall file with the city in January of each year an affidavit approved by the city.
   
6. Date*
   Date
8. Are you 62 years of age or older?*

   1. Yes
   2. No
10. Name*
12. Address*
14. City*
15. Zip Code*
17. Phone Number*
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