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m <br />CITY OF R05L•VILLE <br />Applicatzon £or De£errecl Payment <br />on Special Assessments <br />HAN9 E : <br />STREET AUD�ESS; <br />PRflPERTY IDENTIFICATION M.JaiBER: <br />I, the undersigned, dEClare under the penalties of �erjury, that the <br />followzng special aSSessment(s) were Ievied against the above property after <br />July 27, I981: <br />Project Number <br />1. <br />2. <br />3. <br />4. <br />Auditor Number <br />Assessment Amount <br />$ <br />Average <br />Annual <br />Payment <br />$. <br />_ TOTAL $. � � ' <br />And tha� the total average annual install.ment is in excess of l.o of my federal <br />adjasted gross income (or what my�federal adjusted grvss income would have ' <br />been, if I did not file a federal income tax return) for the year <br />If requested, I will. furnish to the City of Rosevil�e any records that <br />I have which would �e necessary to veri£y the above information. � <br />� <br />�ated . ' <br />flwner(s} SignatureLsj <br />« <br />