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~ ;NAME <br />~_ <br />aDDRES5 <br />CITY/STATE2IP <br />~, t w I EMS FURNISHED <br />9V WNDOWNER <br />- -- - ---- - - - .. ~ ~ ~ ..r IAA <br />FOR LANDOWNERS ONLY <br />j NEW CONSTRUCTION OR IMPROVEMENTS made to your Real ARE THERE~d,081~ OMES LOCATED ON THIS <br />Property during the preceding calendar year. LAND? Yes~.l N0~ NUMBER <br />(DESCRIBE IMPROVEMENTS) iF'YES' UST OWNERS' NAMES AND ADDRESSES BELOW <br />ESTIMdTE~ D CpNSTRUC- V /, <br />~ `~ P~ 3 L« ~f~ ~ 7~ ~ <br />PROPERTY TAX F ~y/ p ~,,,,.S.~vL1Z.i <br />PERSONS: G.S. 105- ~ ~ r~`~ ` _ ~ <br />f$20,Qf~flin assessed <br />65 or older or totally <br />exceed 15 thousand d. <br />home occupied by the ~ <br />InClude3 dll money recen <br />lineal ancestors, or lineal dt:r.o.,~.~.-.. <br />If this application is based upon total and permanent disability, attach a certilidate that <br />certifies that you ' ~ totally and permanently disabled from a phwsidarl licensed as a <br />metlical doctor i. Carolina of ~ !>~varr^9nral a• --~~ ^ter± .:~ --^'~p such <br />determination. <br />(1) IB Ine properly listed an Ihl8 a65~'nee, ::„rr pertrlpneOl rgJpi~enW-il ((,.n <br />(2) What le your dale pf birth? -~ ~ ~_'~~/ ~/ YES NO <br />(3( Did your dispoeipla income Ipr the preceding calgnder year ( ~ (~' <br />exceed 315.0007 <br />VES NO <br />Enter the total disposable income of claimant and sptw3e for Iha preceding Mender year. <br />Claimant~S_~I1_~/ / 7z Spousg $ Q~(~~G~,'~~~ Total $ ~ ~~~7 <br />SIGNEtr' ~~ ~Z'~' " GATEL_L_.~(e <br />NO`S 6 ,_ _ <br />_V- X70 dll®Y11U° <br />w -. <br />-~:... ,~ <br />5 <br />