Ifta Fuel Tax Payment/proposed Adjustments Coupon Template - Michigan
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1Instructions: This form is to be used for payment of an electronically fi led IFTA tax report or for
payment of an adjustment to your report that was initiated by the Department of Treasury. If you
are paying on a proposed adjustment, include a copy of the letter to which your payment ap-
plies. You must use a separate coupon for each payment, however you may write one check. If
you have any questions concerning this form please call the Special Taxes Division, IFTA Sec-
tion at (517) 636-4580.
Detach here and mail in coupon only
Michigan Department of Treasury
4497 (7-09)
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IFTA Fuel Tax Payment/Proposed Adjustments Coupon
Issued under P.A. 119 of 1980, as amended.
CHECK BOX THAT APPLIES
Payment is for a proposed adjustment for the fi le period _________________________
(mm/yy)
Payment is for an original electronically fi led IFTA tax report for the fi le period _________________
(mm/yy)
IFTA Account Number
Business Name
Offi ce Use Only
Payment Enclosed
Make checks payable to “State of Michigan” and mail with this coupon to:
Michigan Department of Treasury; P.O. Box 77692; Detroit, MI 48277-0692
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