Form 4757 - Application For Commercial Facilities Exemption Certificate - Michigan Department Of Treasury Page 2

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Form 4757, Page 2

PART 4: lGu AssEssOR CERTiFiCATiOn

Provide the Taxable Value and State Equalized Value of the Commercial Property.

Taxable Value (excluding land)

state Equalized Value (sEV) (excluding land)

Building

The property to be covered by this exemption may not be included on any other specific tax roll while receiving the Commercial Facilities Exemption. For example, property

on the Eligible Tax Reverted Property (Land Bank) specific tax roll cannot be granted a Commercial Facilities Exemption that would also put the same property on the

Commercial Facilities specific tax roll.

By checking this box I certify that, if approved, the property to be covered by this exemption will be on the Commercial Facilities Exemption specific tax roll and

not on any other specific tax roll.

Name of Assessor (first and last name)

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 in Part 4 of this application is complete and accurate.

Assessor’s Signature

Date