Form Idr 57-150 - Credit Union Statement To Assessor / Confidential Report

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Credit Union Statement to Assessor /
IOWA
Confidential Report
Iowa Code Section 533.329
This form must be filed with your city or county assessor.
Iowa assessors’ addresses can be found at the Iowa State Association of Assessors Web site.
Applicant Contact Information
PLEASE PRINT
Name: ________________________________________________________
Phone Number:___________________ eMail: ________________________
December 31, 20_____
Name of Credit Union:__________________________________________
Address: __________________________________________City, State, Zip: ________________________
SCHEDULE A - LEGAL RESERVES (See 533.303)
Amounts
$ _______________________________________
$ _______________________________________
$ _______________________________________
Total Legal Reserves: $ ________________
SCHEDULE B - SPECIAL RESERVES (See 533.303)
Amounts
$ _______________________________________
$ _______________________________________
$ _______________________________________
Total Special Reserves: $ ______________
Sum Total of Legal and Special Reserves: $ ______________
40,000.00
Less Exemption:
$ ______________
AMOUNT SUBJECT TO TAX:
$ ______________
MULTIPLIED BY FIVE MILL LEVY TAX RATE: _____________
0.005
TAX:
$ ______________
I, _________________________________________________ do testify that this is a true and complete
(Name and Title)
statement in accordance with sections 533.303 and 533.329 of the Code of Iowa, by:
Signature: _________________________________________
Title: _______________________
Credit Union: ______________________________________
Date: _______________________
Notarized by: ______________________________________
Date: _______________________
Date Notary Expires: ________________________________
State: _______________________
IDR 57-150 (03/05/12)

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