Form 4766 - Request For Sales Or Use Tax Exemption For Federally Recognized Indian Tribes Located In Michigan - 2015 Page 2

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4766, Page 2
part 3: seller InformatIon
26. Seller’s Name
27. Seller’s Physical Address
City
State
ZIP Code
28. Seller’s Contact Person
29. Contact Telephone Number
30. Fax Number
31. Seller’s Organization structure
32. Is the retail business wholly owned by the tribe or its members?
(if retailer, list type in space provided; see instructions)
Retailer
No
Unknown
Individual
Yes
33. If yes on line 32, list all owner(s), their principal residence addresses, and whether those addresses are on the tribe’s reservation or trust lands.
If unknown, write “unknown.” (See instructions.) Attach additional sheets if needed.
part 4: certIfIcatIon
I declare under penalty of perjury that I am authorized to file this form on behalf of the tribe and that the information provided is true and complete
to the best of my knowledge.
Authorized Signature
Date
Authorized Signer’s Name (print or type)
Title (if applicable)

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