Copy of Official Affidavit

STATE OF MISSISSIPPI

COUNTY OF GEORGE

AFFIDAVIT

Personally appeared before me, the undersigned authority ill and for said
county and state. ____________________________________, who being by me
first duly sworn, states on oath the following, to-wit:
1. That I am adult resident citizen of George County , Mississippi, who is over the age of 65 years and I am exempt from the George County garbage fee.
2. That I reside at [here state the address of your home]:
_______________________________________________

3. That [here state the name of the individual living with you]
___________________________________________actually resides with me in my home and said individual does not own or rent any other home, mobile home, or apartment in which to live.

4. That I understand that this affidavit will be a public record and may be provided to interested individuals and/or government agencies.

5. That I further understand that, ifI am found to have made a false statement herein, I may be subject to civil and criminal penalties.; including, but not limited to, permanently losing my exemption from the payment of the garbage fee in George County, MS.


____________________________
Affiant


SWORN to and subscribed before me on this the _____ day of

____________________________, A. D.____________


____________________________
NOTARY PUBLIC
In and for George County , Mississippi

(SEAL )