Form 504 - Affidavit Of Assumption By One Corporation For Another - Michigan Department Of Treasury Page 2
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AFFIDAVIT OF TAX ASSUMPTION BY INDIVIDUAL(S)
STATE OF
by Individual(s) Jointly or Severally
)
) ss
for Corporation
County of
)
This form is issued under the provision of the following acts: P.A. 265 of 1947, as amended (Cigarette Tax Act); P.A. 281 of 1967 , as amended (Michigan Income Tax
Act); P.A. 119 of 1980, as amended (Motor Carrier Tax Act); P.A. 67 of 1933, as amended (Sales Tax Act); P.A. 122 of 1941, as a mended (Revenue Act); P.A. 94 of
1937, as amended (Use Tax Act). Filing of this form is voluntary.
WHEREAS, Section 15 of P.A. 167 of 1933, as amended, (Sales Tax Act); Section 5B of P.A. 94 of 1937, as amended, (Use Tax Act); Section 14 of P.A. 265 of 1947, as
amended. (Cigarette Tax Act); Section 451 of P.A. 281 of 1967, as amended, (Michigan Income Tax Act) and Section 14 of P.A. 119 of 1980, as amended, (Motor Carrier
Fuel Tax ), provide that the Corporation Division, Michigan Department of Commerce shall not accept for filing a certificate of dissolution for any corporation organized under
the laws of the State of Michigan or an Application for Certificate of Withdrawal for any corporation organized under the laws of another state and admitted to do business in
Michigan, until the receipt of a notice from the Michigan Department of Treasury to the effect that all taxes levied have been paid, or until it shall have been notified by the
department that the dissolving or withdrawing corporation is not indebted for any taxes:
WHEREAS, it is necessary for the Michigan Department of Treasury to complete an audit of the corporation's books
and records or desk audit(s) of corporation's file(s) in order to determine whether or not there is any deficiency due the
State of Michigan before such notice of deficiency can be issued, and
WHEREAS, in the present case (A) _______________________________________________________________
(Corporation)
State of Incorporation
(A's Federal Employer No.) ___________________________________________________________________________
is desirous of having its
completed immediately and
Dissolution,
Withdrawal,
Merger
because this does not afford the Michigan Department of Treasury sufficient time to complete its audit of the
corporation's books and records, and
WHEREAS, the operations carried on by (A) _______________________________________________ will cease.
(Corporation)
NOW THEREFORE, the undersigned, (B) (Name of Individual(s)) _______________________________________
_______________________________________________ the former ________________________________________
(Title(s)
of (A) _______________________________________________ and in consideration of the fact that the said Department
(Corporation)
of Treasury agrees to execute its Corporation Tax Clearance Certificate immediately, does/do hereby agrees/agree to
jointly and severally file all returns and assume and pay any and all taxes , fees, etc., which are or may be found to be due
to the State of Michigan by the (A) _____________________________________________________________________
(Corporation)
he/she/they agree to send all necessary books and records with original proofs of entries to the said Department of
Treasury at Lansing, Michgan for audit, if requested to do so, or make said books and records available elsewhere if it is
found that said audit must be conducted at a location outside the State of Michigan.
(B)
(A)
Name of dissolving Michigan Corporation of Qualified Foreign
Signature of Individual
Corporation Withdrawing from Michigan.
1. Residential Address
Phone #
(B)
Name of Individual(s) Assuming (A's) Tax Liability (must redide
in Michigan, NOT outstate).
(B)
Signature of Individual
ORIGINAL to be executed, before a Notary. Return ORIGINAL
ONLY to:
1. Residential Address
Phone #
Michigan Department of Treasury
(B)
Collection Division
Tax Clearance Section
Signature of Individual
Treasury Building
1. Residential Address
Phone #
Lansing, Michigan 48922
On this
day of
, 19
, before me a notary public in and for the
County of
, personnaly appeared
who made oath that he/she has read the above Affidavit by him/her subscribed, and that he/she was authorized to do so,
and that he/she knows the contents thereof, and that the same is a true and correct statement.
,
Notary Public:
(City)
(State)
My Commission Expires:
(See Reverse Side for Affidavit of Tax Assumption by ONE CORPORATION for ANOTHER CORPORATION)
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