Form 5565 - Principal Residence Exemption Affidavit For Simil Exemptions In Other States

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Michigan Department of Treasury
5565 (Rev. 10-17)
Office Use Only
Principal Residence Exemption Affidavit for Simil
ar
Date Received
Exemptions in Other States
Issued under authority of Public Act 121 of 2017
MCL 211.7cc(3)(a) requires that owners claiming a Principal Residence Exemption (PRE) complete this form certifying that he/she is not
receiving a substantially similar exemption, deduction, or credit, regardless of amount, in another state, upon request by the Department
of Treasury, the assessor of the local tax collecting unit, the county treasurer, or the county equalization director. This form must be
returned within 30 days of the date this request was issued. For information regarding the Principal Residence Exemption, review the
PRE Guidelines at
PART 1: REQUESTOR INFORMATION
(Local Unit/County/State must complete Part 1)
1. Affidavit Requestor
2. Date of Request
Department of Treasury
Township/ City Assessor
County
3. Address to Return Completed Form
PART 2: MICHIGAN PROPERTY INFORMATION
(Local Unit/County/State must complete Part 2)
4. Property Tax Identification Number
5. Name of Local Unit (Check Township or City)
6. County
Township
City
7. Street Address of Property (Provide a Complete Address)
8. Name of Owner (First, Middle, Last)
9. Name of Co-Owner (First, Middle, Last)
PART 3: CERTIFICATION
(Owner must complete Part 3)
Michigan law states that owners, as defined in MCL 211.7dd, are not eligible for a Principal Residence Exemption on the property listed
in Part 2 if they or their spouse are receiving a substantially similar exemption, deduction, or credit, regardless of amount, on property in
another state.
Certification: I certify under penalty of perjury that I have not claimed or received a substantially similar exemption, deduction or credit on
property in another state.
10. Owner’s Signature
11. Owner’s Last Four Digits of Social Security Number
Date
XXX-XX-
12. Spouse’s Signature
Date
13. Owner’s Spouse’s Last Four Digits of Social Security Number
XXX-XX-
14. Co-Owner’s Signature
15. Co-Owner’s Last Four Digits of Social Security Number
Date
XXX-XX-
16. Co-Owner’s Spouse’s Signature
17. Co-Owner’s Spouse’s Last Four Digits of Social Security Number
Date
XXX-XX-
17. Mailing Address (If Different than Property Address Above)
Failure to return this form within 30 days of the date this request was issued could result in a denial of the Principal Residence
Exemption on the property listed in Part 2. A denial of a Principal Residence Exemption may subject you to additional tax plus penalty
and interest as determined under the General Property Tax Act.
Return completed form to the address listed in Part 1.

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