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Mayor Glenn M. Broska - gbroska@cityofstreetsboro.com
Streetsboro, OH
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Streetsboro, OH
Important Notice from the Streetsboro Water Department:
East Palestine Train Derailment
Mayor Glenn M. Broska
Fee Paid Rubbish
Fee Paid Rubbish Application
Fee Paid Rubbish Application
Date
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Required
MM slash DD slash YYYY
Name
First
Last
Property Address
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Required
Street Address
Address Line 2
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Are you a NEW subscriber to the Fee-Paid Rubbish/Recycling Program?
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Required
Yes
No
Have you been a PAID subscriber for at least one year prior to the date on this application?
*
Required
Yes
No
Do you have an outstanding balance on your account?
*
Required
Yes
No
Have you attached proof of your income for 2020?
*
Required
Yes
No
Have you attached proof of your residency?
*
Required
Yes
No
INCOME SOURCE (Check the Income Source(s) for Your Household) DOCUMENTATION MUST BE PROVIDED!
*
Required
Social Security
Wages
Pension
Child Support
Employment Disability
Interest
VA Pension
Self Employment
Workers Comp
SSDI
Disability Assistance
VA Disability
Unemployment
SSI
Active Military Pay
No Income (Explain how you pay bills on a separate sheet.)
Other (explain)
To select multiple, hold down the CTRL key and select
Explanation to above if you need to add anything.
Upload Documentaion
Max. file size: 25 MB.
Please upload any supporting documentation
If you were not required to file a Federal Income Tax Return, please indicate by checking the box below:
I confirm I was not required to file a Federal Tax Return
Under penalty of falsification, I was not required to file a Federal Income Tax Return for the tax year 2020
Terms and Conditions
Knowingly submitting a false application will require you to reimburse the City for any fees paid on your behalf under this program, and may be subject to prosecution for falsification under R.C. 2921.13. By signing this application below, I affirm/swear that the statements in this application are true and accurate to the best of my knowledge. I do hereby grant permission to the City of Streetsboro, its agents or employees to investigate any and all of the information I have provided.
Signature
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Required
By checking this box, you agree all the information you provided is valid. This checkbox will act as your signature.
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