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Trash & Recycling Senior Citizen Discount Form

2. Senior Discount Form
   Please Complete this form in its entirety.

   Please Complete this form in its entirety.

3. Alternative method - PDF Version of Form
   Senior Discount Trash and Recycling Form (PDF)

   You may also download and print the Senior Discount Form

5. First Name

6. Last Name

8. Co-Resident First Name

9. Last Name

11. Address

13. City

14. State

15. Zip Code

17. I am a resident of Muhlenberg Township and live at the listed address. I understand that by signing this statement, I am indicating that I wish to take advantage of the senior citizen discount rate for Muhlenberg Township trash and recycling services. I certify that I am eligible for this discounted rate because:

    Please choose one option.

    1. I live alone at this address and I am age 65 or older.
    2. I live with no more than one other person at this address and we both are over the age of 65.
    3. I live alone or with no more than one other person at this address and we both are age 65 or older or I am a caregiver for one or two persons of any age with documented disabilities.
19. Note: False statements, including age, address, and occupancy of household may result in the revocation of the senior discount and the Township will be entitled to a refund of all discounts, penalty charges and other remedies provided by law.
    
    I declare under penalty of perjury of law and pursuant to 28 U.S.C. Section 1746 that the foregoing is true and correct statement to the best of my knowledge.

21. Signature of Resident

22. Date
    Date

26. For Office Use Only

28. Account Number

29. Form of Identification Provided

    1. Birth Certificate
    2. Driver's License

    1. Passport
    2. Other

30. Indentification Upload

    Please upload a photo or scan or your identification.

Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

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