Form 4753 - Commercial Rehabilitation Exemption Certification For Qualified Retail Food Establishments - Michigan Department Of Treasury

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Michigan Department of Treasury
4753 (Rev. 6-09)
Commercial Rehabilitation Exemption Certification For
Qualified Retail Food Establishments
Issued under authority of Public Act 210 of 2005.
After completing Part 1, this Qualified Retail Food Establishment Certification form must be submitted by the applicant to the local
governmental unit (LGU) clerk, along with the Application for Commercial Rehabilitation Exemption Certificate and supporting documents.
The LGU shall complete and certify Part 2 of this form. For assistance in determining the property’s qualified LGU designation under A
or B, visit and click on Commercial Rehabilitation Act. If the LGU certifies the requirements
of Part 2, the property may qualify for the exemption and this form and a copy of the “underserved area” description must be submitted
to the Michigan Department of Agriculture at the address listed at the bottom of this form. The Michigan Department of Agriculture will
certify Part 3 of this form and return it to the LGU for submission with the completed application to the State Tax Commission.
PART 1: OWNER / APPLICANT INFORMATION
Applicant (Company) Name (applicant must be the owner of the facility)
Facility’s Street Address
City
State
ZIP Code
Name of City, Township, or Village (taxing authority)
County
School District
City
Township
Village
PART 2: LOCAL GOVERNMENT UNIT (LGU) CERTIFICATION
Certify one of the following:
A.
The property is located in a qualified local governmental unit as defined in Section 2 of the Obsolete Property
Rehabilitation Act (PA 146 of 2000, as amended), OR
B.
The property is located in a qualified local governmental unit that is designated as rural as defined by the United
States census bureau.
Certify the following:
The property was used as residential, commercial, or industrial property as allowed and conducted under the
applicable zoning ordinance for the immediately preceding 30 years.
LGU Representative Name
LGU Representative’s Signature
Title
LGU Address
Date
PART 3: MICHIGAN DEPARTMENT OF AGRICULTURE CERTIFICATION
Certify one of the following:
The property is located in an underserved area.
The property is NOT located in an underserved area. Explain:
Authorization of MI Dept of Agriculture Representative
Signature of Authorized MI Department of Agriculture Representative
Date
Michigan Department of Agriculture
Attn: Agriculture Development Division
PO Box 30017
Lansing, Michigan 48909

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