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Form 10-1980 <br />Rev 6-1985 <br />Rev 8-1990 <br />CITT or ORONO <br />APPLICATION FOR DEFERRAL OF SPECIAL ASSESSMENTS <br />NAMEt <br />HOMESTEAD ADDRESS: <br />PROPERTY IDENTIFICATION (PINS NO.) _________________________________ <br />I, (He), the undersigned, declare under penalties of perjury, the <br />following information is given to the City of Orono and is to be <br />used in evaluating my (our) request for deferral of special <br />assessments levied against my (our) property in accordance with <br />the established policies of Resolution No. 1093, Resolution No. <br />1779 and Resolution No. _____. <br />THIS I«FORMA"IOII WILL BE KEPT CONFIDENTIAL <br />1. 1 am not leas than 65 years of age ard that the date of my <br />birth is _____________________________ * <br />Single Married2. My marital status is: ____ <br />3. List the amount of money you, and your spouse 1l married, <br />receive each month from any of the following sources: <br />RIND OF INCOME RECEIVED <br />1. Wages, Salaries, Commissions, <br />Bonuses, tips, etc. <br />2. Social Security <br />3. Veteran's Benefits <br />4. Other retirement or pension <br />benefits including Railroad <br />Retirement <br />5. Money from renters <br />6. Unemployment ((insurance <br />7. Workers Compensation <br />8. Disability insurance benefits <br />9. Stock dividends <br />10. Interest income <br />11. Income received from other <br />individuals, such as from <br />children, etc. <br />12. Cash Public Assistance <br />13. Gains from Sale or Exchange <br />of property <br />14. Income from businesses or trusts <br />15. ALL OTHER INCOME FROM ANY SOURCE <br />AMOUNT OF INCOME RECEIVED <br />HUSBAND WIFE <br />You should have listed, in the above table, all of the Income <br />receive'^ by you from any source.