Form 4717 - Principal Residence Exemption Database User Id Request

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Michigan Department of Treasury

4717 (1-10)

Principal Residence Exemption Database User ID Request

Issued under the authority of P.A. 206 of 1893.

INSTRUCTIONS: Use one form for each ID requested. Failure to provide complete information for all fields may result in an inability to

process your request. User ID requests are for County and Local Unit employees who audit Principal Residence Exemptions as

part of their official duties. Mail completed request to PRE Database Administration, P.O. Box 30440, Lansing, MI 48909 or fax it to

(517) 335-3264. When access is assigned, notification will be sent to the applicant’s e-mail address listed below.

APPLICANT INFORMATION

(must complete all fields)

Applicant Full Name (Last, First, Middle Initial)

Mailing Address (Address, City, State, ZIP Code)

County/Local Unit

Applicant Telephone Number

Applicant Title

Applicant E-mail Address

APPLICANT AGREEMENT/SIGNATURE

I agree to treat the information contained in the Principal Residence Exemption (PRE) database as privileged and confidential to be used solely for PRE

compliance and auditing purposes. I fully understand that any disclosure, copying, distribution, or use of the contents of this site for any other purpose

is strictly prohibited. I understand that my access to this database may be withdrawn if it is discovered that I am using such information for purposes

other than those intended.

Applicant Signature

Date

COUNTY TREASURER OR EQUALIZATION DIRECTOR AGREEMENT/SIGNATURE

I certify that the above applicant is an employee or authorized representative of the County or of a local unit within the County who is responsible for

conducting PRE compliance audits within the County. I agree to notify the Department of Treasury of any violations of this agreement or when the

applicant is no longer involved in PRE compliance audits.

County Treasurer or Equalization Director Signature

Date

Print Name

Title

DEPARTMENT OF TREASURY USE ONLY

User ID Assigned

Date Approved

Approved by