2. 

4.                                                              CITY OF PASSAIC

6. CLAIMS FOR SENIOR CITIZEN $122 ANNUAL SEWER CHARGE DEDUCTION

8. Requirements
   
   The Claimant must be at least sixty-five (65) years old and the owner of record for the property for which the $122 deduction is claimed.

10. Property Owner's Name:*
12. Address"*
14. Block:*
15. Lot#:*
16. Qualifier:*
18. Is the dwelling (check one): single family home

    1. Yes
    2. No
19. 2 or more family dwelling

    1. yes
    2. no
21. Date of Birth of Claimant: *
    Date of Birth of Claimant:
23. Age verified by:
24. Age Verified by:

    1. Drivers License
    2. Birth Certificate
    3. Passport
25. Other:
27. Verified by:
28. Date:
    Date:
30. Claimant Certification

    CLAIMANT CERTIFICATION:

    I certify that the above declarations are true to the best of my knowledge and I understand that they will be considered as if made under oath and subject to penalties for perjury if falsified.

32. Claimant Signature*
33. Date:*
    Date:
35. FOR OFFICIAL USE
37. Ownership Verified
39. PVWC NOTIFIED
41. DATE
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit Submit and Print

* indicates a required field