Sidewalk Shoveling Exemption Program

First Name *

Last Name *

Suffix

Address *

Phone Number (Home or Cell) *

Phone Number (Caretaker)

Cell Phone

Can we contact you by text?

Yes No

Can we contact you by email?

Yes No

Evidence for Age-based Exemption

Date of Birth *

DC Driver's License Number (or Non-drivers ID) *

Additional Notes

The above information is true and accurate and reflects this household’s existing condition. I acknowledge the District’s right to investigate the information furnished and their right to determine whether a doctor’s statement is needed to verify disability.

Signature (Print Name) *

Signed Date

April 20 2024