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17 <br />OIaAN+OE COUNTS TAX OFFICE <br />ZZ8 SOUTH CHTTRTON STREET; STE Z00 JUDY RYAN <br />P.O. BOX 81$1 DEPUTY ASSESSOR <br />HILLSBOROUGH, NORTH CAROLINA 27278 <br />TELEPHQNE (9i9) 2a5-Zlaa, F_A.~C (919) 6~kF309! <br />Date _ ~2'~b~' <br />To Whom It May Concern: <br />I, ~it~llt 5 S-feYe~ s , am applying for the Circuit Breaker program for the year ~ v~ on <br />Tract # ,~ ~ ~~ ~ ~ I am fully aware of the guidelines of the program. <br />~YD~at'1-Y ! D ~3 <br />I take complete ponsibility in notifying the Tax Office if any of the disqualifying events occur and I <br />am no longer eligible for the program. <br />I am aware that because income changes from year to year it is possible to qualify one year, but not the <br />next. Therefore, the Circuit Breaker program requires an application to be submitted every year. <br />I am fully aware. that the deferred taxes are a lien on the property. <br />By signing this statement I agree to the terms that have been explained to me regarding the Circuit <br />Breaker Tax Deferment Program. ~ '~ <br />Signature y 3~ <br />gnature of owner ' <br />' _.~,.~ . <br />~ -- <br />*Signature <br />signature of kno edgeable family member <br />(preferred but not required) `~ ~ '`'~ ` ~ ~ = '~' ¢ ` ~ ~ ~` ~~" ~ <br />the purpose of this signature is to acknowledge that upon a disqualifying event, the heirs are informed " <br />that the most recent three years of deferred taxes plus interest became due and payable <br />JOHN SM['rE~ 7r.,'CAE <br />ASSESSOR <br />