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t <br />CITY of ROSE I LLE <br />Application for Deferred Payment <br />on Special Assessments <br />�1A�E <br />STREET ADDRESS <br />PROPERTY IDENTIFICATION NUMBER: <br />I, the undersigned, declare under the penalties. of perjury, that the <br />following special assessment (s) were levied against the above property after <br />June 27, 1977: <br />And that the total average annul installment is in eves of 1% of my federal <br />adjusted gross income (or what my federal adjusted gross 'income would have <br />been, if 1 did not file a federal income tax return) for the year <br />If requested, I will furnish to the, of Ros.eville any records that <br />I have which would he necessary to verify the above information, ,. <br />Dated <br />Owner(s) Signature(s) <br />