Form 1411 6/06 - Request For Allocation Template - Michigan Department Of Treasury

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Michigan Department of Treasury

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1411 (Rev. 6-06)

Request for Allocation

Issued under authority of the Federal Deficit Reduction Act of 1984 and executive Order 1984-11 effective September 1, 1984.

You must file this form to apply for allocation against the state ceiling.

MUST BE TYPED OR PRINTED LEGIBLY.

Name of Issuer

County

Year in Which the Bond Will Be Issued

This Request for Allocation is a:

Amendment to Original Request or Previously

New Request

Extension Request

Granted Request

Principal Amount of Issue

If Refund Issued, By What Amount Will Principal Issue Exceed Obligation to be Refunded?

Type of Facility

Description of the Facility to be Financed

Owner of the Facility to be Financed (if known)

Principal users of the Facility (if known)

Name of Law Firm Issuing Tax Exempt Opinion

Legal Counsel Name

Law Firm Address

Telephone Number

Has any previous request been made on behalf of the issuer for the issue?

Yes

If yes, indicate year __________________ sequence number ___________________

Please attach a copy of each of the following:

a. An inducement resolution or other comparable preliminary approval AND

b. A written commitment by an investor or underwriter to purchase the bonds.

Are these bonds to be sold at public sale?

Have all preliminary proceedings to the publication of the notice of sale been

completed?

If yes, please attach a copy of the proposed

Yes

notice of sale.

Are UDAG grants involved in the transaction?

Have TEFRA Hearings been held?

Yes

Filing Deadline: _____________________

Yes

Date: _____________________

Are you required to get an allocation under current statutes?

Yes

If no, is this application for:

a section 501(c)(3) bond?

a housing bond?

an other type of bond?

Please specify. ____________________________________

Will a portion of the bond proceeds be used to fund a debt service reserve?

Yes If yes, please indicate amount and demonstrate that no reasonable alternative to assure debt service payment is available or

desirable.

I hereby certify that the above information is correct and that I have not made or received any bribe, gift, gratuity or direct or indirect contribution to any political campaign for

consideration by the State Treasurer of the allocation request or of the issuer of a request to induce a project and seel allocation.

I understand that a change in the facility to be financed, in the issuer, in the year for which the allocation is sought or in the matter certified by the issuer shall invalidate the

request until an amended request is filed with and approved by the Department of Treasury and shall invalidate any allocation to the extent of the change.

Signature

Type Name and Title

Date

Municipal Address

Telephone Number

Sequence Number

Date Received

INTERNAL

USE

ONLY