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Michigan Department of Treasury
Department of treasury use only
4765 (Rev. 12-11)
Date
Approved
Denied
request for sales or use tax exemption for enrolled resident tribal members
of federally recognized Indian tribes located in michigan
for use by members of tribes that do not have a tax agreement with michigan.
Issued under authority of M.C.L., 205.94(1)(b); U.S. Const., Art.I, §8, cl.3 and Art.VI, cl.2.
part 1: fIler InformatIon
3. Telephone Number
4
1. Filer’s Name
4
2. Social Security Number
4
4. Physical Address of Filer’s Principal Residence
4
City
4
State
4
ZIP Code
4
5. Name of federally recognized tribe or band of which the filer is an enrolled member (see instructions)
6. Item Purchased/to Be Purchased
7. Purchase Price
8. Intended Use of Purchased Item
Personal
Business
Both
your tribe’s
your tribe’s
other michigan
reservation
trust land
location
out of state
9. Location of various transaction components
a. Solicitation ................................................................
.......................
.......................
.......................
b. Payment ...................................................................
.......................
.......................
.......................
c. Signing of Contract ...................................................
.......................
.......................
.......................
d. Exchange of Possession ..........................................
.......................
.......................
.......................
10. Location of filer’s principal residence ..............................
.......................
.......................
.......................
11. Location where item will be used (check all that apply) ....
.......................
.......................
.......................
12. Location of seller .............................................................
.......................
.......................
.......................
4
4
13. Type of Request
14. Refund Amount (if applicable)
Refund
Exemption Letter
part 2: seller InformatIon
15. Seller’s Name
16. Seller’s Physical Address
City
State
ZIP Code
17. Seller’s Contact Person
18. Contact Phone Number
19. Seller’s Organization Structure
20. Is the retail business wholly owned by the Tribe or its members?
(if retailer, list type in space provided; see instructions)
Individual
Retailer
Yes
No
Unknown
21. If yes on line 20, 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 3: CertIfICatIon
I declare under penalty of perjury that the information provided is true and complete to the best of my knowledge.
Filer Signature
Printed Name
Date
1
2
Form 4766 - Request For Sales Or Use Tax Exemption For Federally Recognized Indian Tribes Located In Michigan - 2015
Financial
