Form 4095 - Request And Consent For Disclosure Of Michigan Tax Return Information - 2015

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Michigan Department of Treasury
4095 (Rev. 03-15)
Request and Consent for Disclosure of Michigan Tax Return Information
Issued under authority of Public Act 122 of 1941, MCL 205.1.
The Revenue Act, Public Act 122 of 1941, MCL 205.28(1)(f), makes all information acquired in administering taxes confidential. The Michigan
Department of Treasury recoups cost for preparing copies of tax returns or tax return information requested by local units of government or other third
parties. Taxpayers may receive copies of their personal tax returns at no charge. The current fee schedule is listed below (see Part 3).
PART 1: TAXPAYER INFORMATION
Enter the name of the individual or business, address and account number for which the tax information is being requested.
Taxpayer Last Name
First Name
MI
Social Security Number or FEIN
Telephone Number
Secondary Taxpayer Last Name
First Name
MI
Social Security Number or FEIN
Telephone Number
Address (Street)
City
State
ZIP Code
Tax Type
Income Tax
SBT
MBT
CIT
SUW
Other
Tax Year(s)
Tax Forms
PART 2: AUTHORIZATION
I authorize the State of Michigan, Department of Treasury to furnish tax returns and/or tax return information specified in Part 1 to the appointee listed
below. This authorization expires in six months and is not a substitute for a formal Form 151, Authorized Representative Declaration.
Appointee Name
E-mail Address
Telephone Number
Address (Street)
City
State
ZIP Code
Signature of Taxpayer OR Legal Representative
Date
Signature of Taxpayer OR Legal Representative
Date
PART 3: FEE SCHEDULE
Local units of government or other third parties must pay the fee described here. Taxpayers may receive copies of their personal tax returns at no
charge. Payment for tax return information must accompany the request. Make checks payable to the State of Michigan and write index code # 19182
on the check. * Large requests will be assessed differently.
First Year
$ 5.00
$5.00
Additional Year(s)
$ 3.00 X _________
FEE TOTAL
Please allow 60 days for processing your request.
Submit your request with payment to the following address:
Michigan Department of Treasury
Office of Privacy and Security, Disclosure Unit
430 W. Allegan Street
Lansing, MI 48922
Telephone: (517) 636-4239
Treasury Use Only
1.
The attached information is furnished for tax year(s) __________________________________________________________
__________________________________________________________________________________________________________
2.
No record of filing a return for tax year(s) ___________________________________________________________________
3.
The account number submitted needs to be verified for accuracy.
4.
The account number provided is being used by another taxpayer.
5.
Other _____________________________________________________________________________________________________
__________________________________________________________________________________________________________
Disclosure Office Approval
Fee Received
Date Completed

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