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<br />APPLICATION FOR DEFERMENT OF SPECIAL ASSESSMENTS <br /> <br />fit <br /> <br />To the City Council of City of Elk River, Sherburne County, Minnesota. <br /> <br />(Applicant) being <br /> <br />first duly sworn deposes and states: <br /> <br />1. That Applicant is the owner of the following described real estate located in the City of <br />Elk River, Sherburne County, Minnesota: <br /> <br />2. Pursuant to Minn. Stat. S435.193, et. seq. and Elk River Code of Ordinances S1404, <br />Applicant requests deferral of the payment of special assessment for the <br />Improvement. <br /> <br />3. In support of this request, Applicant represents as follows: <br /> <br />a. Applicant is over 65 years of age; <br /> <br />b. <br /> <br />Applicant is permanently and totally disabled as follows: <br /> <br />. <br /> <br />c. Applicant's adjusted gross income is $ <br /> <br />4. Applicant declares that the foregoing information is true and correct and agrees to <br />immediately inform the Elk River City Administrator should any of the foregoing <br />information change, and agrees that if the deferral is granted, Applicant will immediately <br />upon termination of the deferral pay to the City the deferred assessment with interest. <br /> <br />Dated: <br /> <br />Applicant <br /> <br />Subscribed and sworn to <br />before me this day <br />of , 1989 <br /> <br />Notary Public <br /> <br />. <br /> <br />A-33 <br />