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2. Single-Use Bag Fee Exemption

   This form serves to notify the City of Lafayette that the major store named believes that it should not collect a Single-Use Bag Fee as outlined in Colorado House Bill 21-1162. Once this form is received by the City, your request will be reviewed, and you will be notified within 20 business days whether the Single-Use Bag Fee will apply to your business. The review process may include a site visit to your business.

   Please answer the following questions. All fields (even those not marked with an asterisk) are required. 

4. Retailer Information

   Please provide some information about your business and who to contact about the status of the exemption or questions. 

6. Company Name*
8. Lafayette Taxpayer ID*

   This six digit number can be found on your business license.

10. Type of Business (i.e. grocery store, convenience store, etc.)
12. Physical Location Address
14. Primary Contact Name*
16. Phone Number*
18. Email*
20. Is your business a store that operates solely in Colorado and has three or fewer locations?

    1. Yes
    2. No
22. Does your business provide single-use carryout bags (plastic, paper and/or other material) to customers at the point of sale?

    1. Yes
    2. No
24. In 200 words or less, please explain why you believe the bag fee does not apply to your business.

    Please refer to HB 21-1162 before submitting your answer.

26. Thank you! 

    Once the form is received, staff will in in contact within 20 business days regarding the status of your exemption.

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field