Form 150-491-646 - Application For Deferral Of Special Assessment On Senior Citizens' Residential Property - 2010
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Application for Deferral of Special Assessment
FOR OFFICIAL USE ONLY
Date received at bonding office
on Senior Citizens’ Residential Property
(ORS 311.702-735)
Date received at Department of Revenue
• File your completed application with the taxing district bonding officer after
October 1 and by November 30.
• You must complete the Income Worksheet on the back of this application.
• Remember to sign your application.
Filed with the _______________________________ Bonding officer for ___________ (year) and prior calendar years.
Applicant type: Individual
Joint
RDP
Refiling as surviving spouse
New marriage
Divorce
Applicant’s name (last, first, M.I.)
Social Security number
Birth date
Age
•
•
—
—
Joint applicant’s name (last, first, M.I.)
Birth date
Social Security number
Age
•
•
—
—
Mailing address
City
State
ZIP code
•
•
•
•
Telephone number/message/e-mail address
Property address (if different than mailing address)
Now go to the back of the form ➙
THIS SPACE FOR BONDING OFFICER’S USE ONLY—MUST COMPLETE
Bonding officer’s account
Date entered on bond lien docket
Bond lien docket number
Kind of bonds
Certified copy of the installment agreement attached
Amortization
Please provide an amortization of payment/amounts for each installment for the life of the assessment.
First installment Jan 1–Jun 30: Due August 1
$ ________________
Second installment Jul 1–Dec 31: Due February 1 $ ________________
Delinquent installment: Due by January 31
$ ________________
DESCRIPTION OF PROPERTY
Model year
Make
Home number
Square footage
# of bedrooms
Real Manufac-
tured Structure
# of bathrooms
Roofing material
Siding type
Heating system
Cooling system
(Mobile Home)
Platted
Lot _________________________
Blk _____________________
_____________________________________________________________________ Legal Desc
For all unplatted properties attach a copy of the recorded deed or contract.
T _________________________
R ___________________________
Sec ______________________________________
Parcel in:
Unplatted
As described in ____________________________________________________ County
Containing______________________________ acres
Deed information
Contract recorded in (year) _______________________
Deed recorded in (year) _______________________
Deed
Document/instrument number
Microfilm number
Reel
Book/volume
Page
Assessor’s account number
Levy code
BONDING OFFICER’S CERTIFICATION
Note: If more than one special assessment is being deferred, each requires a separate application. If this is the first application for deferral of
this property, A CERTIFIED COPY OF THE AGREEMENT allowing payment of the special assessment by installment must be attached.
I certify that the above is a true statement of the total amount due.
Bonding officer signature
Title
Date
County
No.
X
—THIS SPACE FOR DEPARTMENT OF REVENUE USE ONLY—
Approved by (initials) Date approved
Denied by (initials)
Date denied
Bonding district no.
Application denied
Application approved
150-491-646 (Rev. 08-10)
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