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16/00 09:25 FAX 612 422 2940 HOFFMAN C�004 <br />IIIIIIIIr <br /> BY;COON RAPIDS CITY 2- 7- 0 ;12:01PM ; FINANCE DEFT 612 422 2840;# 2/ 2 <br /> 11111 USERS WHO RESIDE IN COON RAPIDS AND MEET THE FOLLOWING <br /> REQUIREMENTS API ENTITLED TO A REDUCED SEWER CHARGE: <br /> (A) Are 62 years of age or members of a household in which one(1) of the spouses is 62 years <br /> of age or older and the other is not gainfully employed; and <br /> (13) Occupy the unit with not more than two (2) other persons who are also 62 years of age or <br /> older or occupy the unit with a person under 62 years of age who is not gainfully employed; <br /> or <br /> (C) Occupy a unit as homestead/owner occupied property which qualifies for 1B Classification <br /> pursuant to MN Statutes Section 273.13, Subdivision; or <br /> (D) Have received an award letter from the Social Secrity Administration indicating the individual <br /> is one hundred percent (100%) disabled and entitled to Social Security Benefits for such <br /> disability; or <br /> (E) Have received an award letter and/or formal statement from any other pension administration <br /> indicating the individual is one hundred(100%) percent disabled and is entitled to benefits <br /> from that pension administration for such disability; and <br /> (F) Are directly billed for sewer charges by the City; and <br /> (G) File an affidavit verifying that the user meets the above requirements. <br /> 1110 Return this form to the Cry of Coon Ranids. 11155 Robinaeo Drive.Coon Rapids,MN 55433 <br /> APPLICATION FOR REDUCED SEWER RATE <br /> AND/OR <br /> WAIVER OF WATER SERVICE CHARGE <br /> I,THE UNDERSIGNED, DECLARE UNDER THE PENALTIES OF PERJURY THAT I AM A <br /> CITIZEN OF COON RAPIDS WHO QUALIFIES FOR A REDUCED SEWER CHARGE AND/OR <br /> WATER. SERVICE CI-IARGE AS PROVIDED IN SECTION 13-301 AND 13-604(2) OF THE <br /> CITY CODE AS AMENDED. <br /> It is requested the municipal billings for the home located at: <br /> reflect charges for sewer and/or water service use at the appropriate rate. <br /> SIGNATURE: SOCIAL SEC. # <br /> STREET ADDRESS: DATE OF BIRTH: <br /> DRIVERS LICENSE: DATE: <br /> ACCOUNT NUMBER: <br /> SO <br />