Form L-4155/628 - Notice By Owner Of Property Incorrectly Reported Or Omitted From Assessment Roll Page 2

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628, Page 2
INSTRUCTIONS: This side is to be completed by the assessor.
SUPPLEMENTAL TAX RATE INFORMATION
If this notice is for either of the tax years immediately preceding the current year, the assessor shall list for each year the total tax rate
levied in the city or township in which the property is located. The total annual tax rate levied must include the total village tax rate, if
applicable. The listing must reflect any millage reduction due to the Principal Residence Exemption, the Qualified Agricultural
Exemption, the Qualified Forest Exemption, the Industrial Facilities Exemption, the Commercial Personal Property Exemption or the
Industrial Personal Property Exemption. If this notice is for omitted real property upon which "millage rate" special assessments were
levied, list those rates separately below. Do not include special assessments levied in specific dollar amounts.
Year Covered By Notice
SUMMER
WINTER
Total Annual Tax Rate Levied
Total Tax Rate Levied
Total Tax Rate Levied
SPECIAL ASSESSMENT RATES. Complete lines below for special assessment millage rates only
Year Covered By Notice
SUMMER
WINTER
Total Annual
Special Assessment Rate Levied
Special Assessment Rate Levied
Special Assessment Rate Levied
Is this property assessed on the Industrial Facilities Tax Assessment Roll, the Commercial Facilities Tax Assessment Roll, the Technology Park
Facilities Assessment Roll, the Neighborhood Enterprise Zone Assessment Roll, the Renaissance Zone assessment or as an Act 189 of 1953
assessment?
If yes, specify which roll:_______________________________________________
Yes
No
PERSONAL PROPERTY NOTICES ONLY: Did the owner complete and deliver a personal property statement (L-4175) for each year that this notice
covers that was:
Timely Filed? (Accepted as filed and actually used in the assessment that was confirmed by the Board of Review?)
OR
Estimated/Not filed? If estimated or not filed, indicate years:_______________________________
CONCURRENCE OR DISAGREEMENT WITH THIS REQUEST
This section must be completed by the assessor or equalization director.
I AGREE with this request for corrected Assessed Value and/or Taxable Value.
I DO NOT AGREE with this request for corrected Assessed Value and/or Taxable Value. The assessor or equalization director who checks
this box must submit to the State Tax Commission an explanation of the reason for not concurring.
Name of Assessor or Equalization Director
Title
Assessor Certification Number
Address (Number, Street, City, State and ZIP Code)
Signature of Assessor or Equalization Director
Date
Telephone Number
Comments or Explanations
Assessor or Equalization Director Email Address
Return this completed form to:
State Tax Commission
Michigan Department of Treasury
P.O. Box 30471
Lansing, MI 48909-7971

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