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2. Curbside Garbage & Recycling Exemption Form
   Submit this form if you have a physical or other limitation that prevents you from complying with the curbside collection program. By submitting this form you are certifying that neither you nor anyone in your home is capable of rolling a garbage or recycling cart out to the curb for collection. Residents requesting an exemption from curbside garbage collection must submit a letter from their medical provider verifying the need for an exemption. Garbage exemptions are good for three years. See details below.
4. Today's Date*
   Today's Date
6. First Name*
7. Last Name*
9. Address*
11. City*
12. Zip Code*
14. Phone Number*
15. Email Address
17. Exemption Request*

    Please select

    1. Garbage only (Medical verification required. Must agree to terms & conditions for garbage exemptions. See below.)
    2. Recycling only (Medical verification required. Must agree to terms & conditions for recycling exemptions. See below.)
    3. Garbage & Recycling (Medical verification required. Must agree to terms & conditions for both garbage and recycling exemptions. See below.)
19. Medical Verification Letter
20. Under the City Code, exemptions for curbside garbage collection will be approved only with a letter from a medical provider verifying that neither the applicant nor anyone living in the house is capable of rolling out the garbage cart. THIS LETTER MUST BE DATED AND PRINTED ON THE MEDICAL PROVIDER'S LETTERHEAD. If you have an electronic copy of the letter use the CHOOSE FILE button to attach a copy to this application. (If your provider does not send you the letter electronically, all branches of the Forsyth County Public Library have scanners for public use that can create an electronic copy of your verification letter.)
22. Garbage Exemption Terms & Conditions*

    Your application for a garbage exemption will not be accepted unless you read and agree to these terms and conditions, using the check box below.

    •You must provide your own personal garbage can(s). The 96-gallon city-issued cart can NOT be used for this service.

    •You are allowed up to two (2) 45-gallon cans or three (3) 33-gallon cans.

    •Your trash can(s) must be easily accessible and not enclosed in a fence, garage or locked compartment.

    •Service may not be available during inclement weather.

    •There must be no one in the home capable of bringing a garbage cart to the curb.

    •You must provide a letter from your medical provider certifying that neither you nor anyone in your household is capable of rolling a garbage cart to the curb.

    •The letter must be dated and printed on the medical practice letterhead.

    •Your application will not be processed until we receive BOTH this application and your medical verification letter.

    •You must reapply for an exemption with a new medical verification letter every three (3) years.

    •If you do not reapply you will be removed from the exemption list.

    
    

    I certify that I have read and agree with all terms and conditions for garbage curbside collection exemptions. I also certify that I understand that it is a violation of the City Code to falsely certify my household’s status.

    1. I AGREE
24. Recycling Exemption Terms & Conditions*

    Your application for a recycling exemption will not be accepted unless you read and agree to these terms and conditions, using the check box below.

    •There must be no one in the home capable of bringing the rollout cart to the curb.

    •Recyclables should be placed in the blue recycling cart.

    •Your recycling cart must be easily accessible and not enclosed in a fence or garage.

    •Service may not be available during inclement weather.

    
    

    I certify that I have read and agree with all terms and conditions for recycling curbside collection exemptions. I also certify that I understand that it is a violation of the City Code to falsely certify my household’s status.

    1. I AGREE
26. Next Step
    Allow at least two weeks for your exemption application to be processed. If your application is approved it will be stamped as received and you will be sent a copy. If the exemption is for curbside garbage collection your copy will also be stamped with the date that your exemption will expire.
28. Contact Information
    GARBAGE
    Johnita Campbell, Deputy Sanitation Director
    P.O. Box 2511 Winston-Salem, NC 27102-2511
    
    RECYCLING
    Helen Peplowski, Sustainability Manager
    P.O. Box 2511 Winston-Salem, NC 27102-2511
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30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

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