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APPLICATION FOR ASSESSMENT DEFERRAL <br />SECTION 1 Î APPLICANT INFORMATION <br />APPLICANTÓS FULL LEGAL NAME (LAST, FIRST, MIDDLE) <br />APPLICANTÓS MAILING ADDRESS (STREET ADDRESS, CITY, STATE, ZIP) <br />APPLICANTÓS PHONE NUMBER APPLICANTÓS DATE OF BIRTH <br />SECTION 2 Î PROPERTY INFORMATION <br />STREET ADDRESS OF PROPERTY <br />PARCEL IDENTIFICATION NUMBER <br />SECTION 3 Î DEFERRAL INFORMATION <br />ASSESSMENT NUMBER <br />NAME OR TYPE OF ASSESSMENT <br />REASON FOR DEFERRAL: <br />Deferral of homestead property for (check one or more of the following): <br />Person 65 years of age or older for whom it would be a hardship to make the payments. <br /> <br />Person who is retired by virtue of permanent and total disability for whom it would be a hardship to make the payments. <br /> <br />Person who is active member of any of the U.S. armed forces, Minnesota National Guard or other military orders, for <br /> <br />whyments. <br />om it would be a hardship to make the pa <br />SECTION 4 Î SUPPORTING EVIDENCE <br />(e.g. DriverÓs License or other state ID; most recent Federal Income Tax Return; an affidavit from a physician stating the <br />permanent disability and is unable to perform any kind of work) <br />applicant has a <br />I certify that the information given herein is true and complete to the best of my knowledge. <br />Signature of Applicant Date <br />FOR OFFICE USE ONLY <br /> APPROVED DENIED <br />REASON FOR DENIAL: PROJECT NO: ASSESSMENT NO: <br /> DESCRIPTION: <br />LEVIED DATE: INTEREST RATE: <br />TERM OF ASSESSMENT (NON-DEFERRED): <br />AMOUNT OF PRINCIPAL TO BE DEFERRED: <br />Signature of Assessments Supervisor Date <br />Qbhf!63!pg!248 <br /> <br />