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I state that the purpose of this declaration is to qualify for and apply for a credit or refund for the charge imposed by Section 244:15 of the Code of Ordinances for the City of St. Cloud, Minnesota, for which I have been billed. Per section 244:70 of the City Code, any person who submits a false affidavit in support of an application for credit or refund provided herein, will be guilty of a misdemeanor. I certify that I am the owner, or the legal representative for the owner of the residence located at:
That said residence was vacant & unoccupied from dates below. (NOTE: vacancy period MUST BE a minimum of 60 days / 2 months to receive credit!)
That during this period, no refuse was accumulated or collected by the City of St. Cloud Sanitation Division at the premises on which said residence was located.
The Minnesota Data Privacy Act requires that we inform you of your rights about the private data we are requesting on this form. The following data contained on this form will be considered private data pursuant to M.S. 13.548: the name, address, telephone number, any other data that identifies the individual, and any data that describes the health or medical condition of the individual, family relationships, and living arrangements of an individual or which are opinions as to the makeup or behavior of an individual. We need this data to register you for a program and to contact you if necessary. City of St. Cloud staff will have access to the data you provide to administer the program. You are not legally required to provide the data; however, refusing to supply the data may cause your registration to not be processed. Your acceptance here indicates you have read and understand these rights.
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