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Form 2743 (Formerly T-1072) - Request To Rescind Qualified Agricultural Property Exemption - 2001

Michigan Department of Treasury, PTD

Issued under P.A. 237 of 1994,

2743 (6-01) Formerly T-1072

as amended. Filing is mandatory,

penalties are specified below.

REQUEST TO RESCIND QUALIFIED AGRICULTURAL PROPERTY EXEMPTION

If all or a portion of your property is no longer qualified agricultural property, you must file this form to rescind your

claim. File within 90 days of the change. The exemption will remain in place through December 31. An owner who fails

to rescind an exemption is subject to a penalty of $5 per day (maximum $200) for each separate failure.

1. Enter below the property tax identification number of property being rescinded, including hyphens.

2. ZIP Code

3. Street Address of Property

4. Name of Township/City

5. County of Property

Township

City

6. Check this box if a homestead is located on the property identified above.

7. If the percentage of property that qualifies for this exemption has changed,

enter the new percentage here. (See back for definition of qualified property.)

8. Name of Owner (first, middle, last)

Name of Co-Owner (first, middle, last)

Use the space below for any other information that may help us process your request.

Owner's Certification

I certify that all or a portion of the property identified above is no longer qualified agricultural property.

Owner's Signature

Date

Co - owner's Signature

Date

File this form with assessor or supervisor in the township or city where the property is located.

Form 2743 (Formerly T-1072) - Request To Rescind Qualified Agricultural Property Exemption - 2001