Form 3874 - Michigan Tax Amnesty Supplemental Schedule - 2011

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Michigan Department of Treasury
1. Taxpayer’s Social Security Number
3874 (Rev. 03-11)
Michigan Tax Amnesty
2. Federal Employer Identification Number (FEIN)
Supplemental Schedule
Complete this schedule if there was not enough space for you to enter all of your return/payment information on
page 1, Part 2 of the Michigan Tax Amnesty Application (Form 3855). Enter the total amount from this schedule
on Form 3855, Line 20.
PART 2, TAX PAYMENT DETAIL (Continued)
E
H
D
F
A
B
C
G
Amount of
Taxable Period
Amount of
Total Tax and
Tax Type
Assessment
Tax Due
(MM/YYYY)
Interest Due
Interest Due
Code
Number
(X)
(C)
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
TOTAL AMOUNT ON THIS SCHEDULE.
(Enter this amount on Form 3855, Line 20)
Attach this completed schedule to the Michigan Tax Amnesty Application (Form 3855).

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