Form 4757 - Application For Commercial Facilities Exemption Certificate - Michigan Department Of Treasury

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Michigan Department of Treasury
sTATE usE Only
4757 (Rev. 08-09)
Application Number
Date Received
LUCI Code
Application for Commercial Facilities Exemption Certificate
Issued under authority of Public Act 255 of 1978, as amended.
Read the instructions page before completing the application. This application must be filed after a Commercial Redevelopment District is
established. The original application and required documents are filed with the clerk of the Local Governmental Unit (LGU).
PART 1: OwnER / APPliCAnT inFORmATiOn
(applicant must complete all fields)
Applicant (Company) Name
NAICS or SIC Code
Facility’s Street Address
City
State
ZIP Code
Name of City, Township or Village (taxing authority)
County
School District Where Facility is Located
City
Township
Village
Date of Rehabilitation Commencement (mm/dd/yyyy)
Planned Date of Rehabilitation Completion (mm/dd/yyyy)
Estimated Cost of Rehabilitation
Number of Years Exemption Requested (1-12)
Expected Project Outcomes (check all that apply)
Increase Commercial Activity
Retain Employment
Revitalize Urban Areas
Increase Number of Residents in Facility’s Community
Create Employment
Prevent Loss of Employment
No. of perm. jobs to be created due to facility’s rehab. No. of perm. jobs to be retained due to facility’s rehab. Number of construction jobs to be created during rehabilitation
Each year, the State Treasurer may approve 25 additional reductions of half the state education tax for a period not to exceed six years.
Check this box if you wish to be considered for this exclusion.
PART 2: APPliCATiOn DOCumEnTs
Prepare and attach the following items:
General description of the facility (year built, original use, most recent use,
Descriptive list of the fixed building equipment that will be a part of the facility
number of stories, square footage)
Time schedule for undertaking and completing the facility’s restoration,
General description of the facility’s proposed use
replacement or construction
General description of the nature and extent of the restoration, replacement, or
Statement of the economic advantages expected from receiving the
construction to be undertaken
exemption
Legal description of the facility
PART 3: APPliCAnT CERTiFiCATiOn
Name of Authorized Company Officer (no authorized agents)
Telephone Number
Fax Number
E-mail Address
Mailing Address
City
State
ZIP Code
I certify that, to the best of my knowledge, the information contained herein and in the attachments is truly descriptive of the property for which this
application is being submitted. Further, I am familiar with the provisions of Public Act 255 of 1978, as amended, and to the best of my knowledge the
company has complied or will be able to comply with all of the requirements thereof which are prerequisite to the approval of the application by the local
governmental unit and the issuance of a Commercial Facilities Exemption Certificate by the State Tax Commission.
I further certify that this application relates to a program, when completed, will constitute a facility, as defined by Public Act 255 of 1978, as amended.
Signature of Authorized Company Officer (no authorized agents)
Title
Date
Continue on Page 2

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