Form L-4111 - Real Property Statement
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1
2Michigan Department of Treasury, STC
This form is issued under authority of P.A. 206
L-4111 (12-95)
of 1893. Filing is mandatory. Failure to file is
punishable by fine and/or imprisonment.
REAL PROPERTY STATEMENT DECEMBER 31, 19 ______
This statement must be returned on or before
To be filed with:
Name of Business
Address (Post Office, RR#, City, State, ZIP)
Check Type of Organization
Owners Names
Corporation
Nature of Business
Partnership
Location of Main Office
Individual
Year
Purchased
Size
Cost
LAND
Total
Year
Type
Cost
LAND
IMPROVEMENTS
Total
Year
Year
Built
Purchased
Type
Cost
BUILDING
ATTACHED EQUIPMENT
Total
Year
Year
Built
Purchased
Type
Cost
BUILDING
ATTACHED EQUIPMENT
Total
Year
Year
Built
Purchased
Type
Cost
BUILDING
ATTACHED EQUIPMENT
Total
Year
Completion
REAL PROPERTY
Started
Date
Type of Construction
Cost to Date
CONSTRUCTION IN
PROGRESS
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