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2. 
3. Affidavit of Indigence-FOIA (Appendix D)

   City Clerk Jennifer A. Zelmanski

   (586) 445-5443

5. Personal Information
7. Name*
9. Street Address*
11. City*
12. State*
13. Zip Code*
15. Contact Phone Number*
16. Age*
18. Number of Dependants*
19. Ages of Dependants*
21. Are you a student?*

    1. Yes
    2. No
22. Part Time/Full Time*

    1. Part Time
    2. Full Time
    3. Not Applicable
23. Name of School you attend
25. Marital Status*

    1. Single
    2. Married
    3. Divorced
    4. Separated
    5. Widowed
29. Current or Most Recent Employer's Name*
30. Responsible Party for Placing Signs Email Address*
32. Current or Most Recent Employer's Address*
34. Current or Most Recent Employer's Phone Number*
35. Dates of Employment*
    Dates of Employment Start Date

    —

    Dates of Employment End Date
37. Monthly Income*

    Please include Child Support and/or Alimony

38. Spouse's Monthly Income*

    Please include Child Support and/or Alimony

40. Total Monthly Household Expenses*

    Rent/Mortgage, Car Payment, Utilities, Groceries, Installment Payments, etc.

41. Are you on Public Assistance?*

    1. Yes
    2. No
42. Are you requesting this Waiver of Fees on behalf of another person who has offered you money to do so?*

    1. Yes
    2. No
44. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    I further attest that all of the statements made herein are true and correct and that I am considered to be indigent.

    1. I agree.
46. Electronic Signature*
48. Date*
50. Non-Electronic Submittal Instructions

    If you choose to print this application, please mail or hand deliver it to the City Clerk's Office- City of Roseville- 29777 Gratiot Avenue, Roseville, MI  48066.

    License will be issued by the City Clerk if approved.

Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit

* indicates a required field