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APPLICATION FOR DEFERMENT OF SPECIAL ASSESSMENTS <br /> To the City Council of St Anthony, Minnesota. <br /> (Applicant) being first duly <br /> deposes and states: <br /> 1. That Applicant is the owner of the following described real estate located in the City <br /> of St Anthony, Minnesota: <br /> 2. Pursuant to Minn. Stat. S435.193, et. seq. and the St Anthony Assessment Policy, <br /> Applicant requests deferral of the payment of special Assessment for the <br /> Improvement. <br /> 3. In support of this request, Applicant represents as follows: <br /> a. Applicant is over 65 years of age; <br /> • b. Applicant is permanently and totally disabled as follows: <br /> C. Applicant's adjusted gross income is $ <br /> 4. Applicant declares that the foregoing information is true and correct and agrees to <br /> immediately inform the St Anthony City Administrator should any of the foregoing <br /> information change, and agrees that if the deferral is granted, Applicant will <br /> immediately upon termination of the deferral pay to the City the deferred assessment <br /> with interest. <br /> Dated: <br /> Applicant <br /> Subscribed and sworn to <br /> before me this day <br /> of , 19 <br /> • Notary Public <br />