Laserfiche WebLink
mak <br /> • <br /> 7.Signature of Taxpayer: If signed by a corporate officer,partner,guardian,tax matters partner/person,executor,receiver,administrator or trustee <br /> on behalf of the taxpayer,I certify that I have the authority to execute this form on behalf of the taxpayer. <br /> The following applies if the authorized representative is a Certified Property Tax Representative pursuant to 50 IAC 15.5.5: <br /> I understand that by authorizing as my Certified Property Tax Representative,I am aware of and accept the possibility <br /> that the property value may increase as a result of filing an administrative appeal with the Property Tax Assessment Board of Appeals,and that I may be <br /> compelled to appear at a hearing before the Property Tax Assessment Board of Appeals or the Department of Local Government Finance. <br /> I further understand that the Certified Property Tax Representative Is not an attorney and may not present arguments of a legal nature on my behalf. <br /> If this power of attorney Is not signed,dated and notarized,it will be returned. <br /> Date of signature(month,day,yew) <br /> Signature oitaxpayer • <br /> Printed name of taxpayer Title(If applicably,) tt <br /> David Heckaman _ rlri° 5 ide vifi <br /> Date of signature(month,day,year) <br /> Signature of taxpayer <br /> Printed name of taxpayer Title(if applicable) <br /> 8.Notarization <br /> STATE OF SS: <br /> COUNTY OF <br /> Before me,a notary public in and for said state and county,personally appeared,this day of <br /> the taxpayer(s)or a person duly authorized to sign for and on behalf of the taxpayer(s),who acknowledged the execution of this Power of Attorney as <br /> the voluntary act and deed of the taxpayer(s). <br /> Signature of notary public County of residence <br /> Typed or printed name of notary public Dale commission expires(month,day,yew) <br /> PART II-DECLARATION OF REPRESENTATIVE <br /> Under penalties of perjury,I declare that <br /> I am aware of the statutes,rules and regulations applicable to the matters specified in line 3; <br /> I am authorized to represent the taxpayer(s)identified in Part I for the tax matter(s)specified there;and <br /> I am one of the following: <br /> a. Certified Public Accountant-duly qualified to practice as a certified public accountant in the jurisdiction shown below. <br /> b. Certified Tax Representative pursuant to 50 IAC 15-5. <br /> c. Other(specify) <br /> If this declaration of representative Is not signed and dated,the power of attorney will be returned. <br /> DESIGNATION JURISDICTION(state,etc.)OR SIGNATURE DATE(month,day,year) <br /> (insert above letter-a,b,or c) ENROLLMENT CARD NUMBER <br /> '4 „ ' 74( <br /> b Indiana �!_r, J; ��,`v.W 1 ti... Z.. <br /> Indiana t1 i 0,61 /c7... i <br /> a Filed III ` ;< 7 <br /> N{ oV15ZO712 <br /> CM CLER ►r bi)ta(h BEND,IN <br /> Page 2 of 2 <br />