Form L-4175 - Personal Property Statement - 2016
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This form must be completed
and returned to the assessor by
Michigan Department of Treasury
Parcel No.
February 20, 2016.
632 (Rev. 12-15)
2016
Issued under authority of Public Act 206 of 1893.
L-4175
Approved by the State Tax Commission October 12, 2015.
2016 Personal Property Statement
(As of 12-31-15)
Location(s) of Personal Property Reported on This Statement.
FROM:
(Name and Address of Assessor)
LIST ALL LOCATIONS. Attach additional sheets if necessary.
Square Feet
Date of Organization
Date Business Began at
Occupied
above location
Assumed Names Used by Legal Entity, if any
TO:
Names of Owner(s) or Partners
(Name and Address of Taxpayer)
(If sole proprietorship or partnership)
If Sole Proprietorship, Taxpayer's Residential Address
Legal Name of Taxpayer
Address Where Personal Property Records are Kept
Check One Only:
Preparer's Name, Address and Telephone Number and E-mail address
Sole Proprietorship
Name of Person in Charge of Records Taxpayer Telephone No.
Partnership
Limited Liability Co.
Description of Taxpayer's Business Activity and NAICS Code
Corporation
MI ID# ______________
NOTICE: Pursuant to P.A. 153 of 2013, if the true cash value of the assessable personal property you or a related party own, lease or possess
in this local assessing unit is less than $80,000, then you need not file this form if you file Form 5076 with the local unit where the property is
located no later than February 10, 2016. DO NOT USE THIS FORM TO CLAIM AN EXEMPTION AS ELIGIBLE MANUFACTURING PERSONAL
PROPERTY (EMPP) PURSUANT TO MCL 211.9m AND MCL 211.9n. To claim an exemption for EMPP, file Form 5278 with the local assessor
where the personal property is located no later than February 20, 2016. See the instructions at Page 5.
SUMMARY AND CERTIFICATION. Complete ALL questions.
If Yes, state total original cost
excluded _________________
1.
Have you excluded any exempt "Special Tools" from this statement?
Yes
No
2.
Have you excluded any air and water pollution control facilities and/or wind or water
Yes
No
If Yes, attach itemized list.
energy conversion devices for which an exemption certificate has been issued?
3.
Have you, to the best of your knowledge, reported all of your assessable tangible
personal property located in Michigan including fully depreciated and/or expensed
Yes
No
If No, attach explanation.
assets, to the appropriate assessment jurisdiction?
4.
Did you hold a legal or equitable interest in personal property assessable in this
Yes
No
If Yes, attach itemized list.
jurisdiction which you have not reported on this statement (see instructions)?
5.
Are you a party (as either a landlord or a tenant) to a rental or lease agreement relating
Yes
No
If Yes, complete Section O.
to real property in this jurisdiction?
6.
Have any of your assets been subjected to "rebooking" of costs for accounting
Yes
No
If Yes, attach itemized list.
purposes or been purchased used (see instructions)?
Yes
No
If Yes, attach Form 3595.
7.
Is any of your property "daily rental property," per P.A. 537 of 1998?
Yes
No
If Yes, attach itemized list.
8.
Are other businesses operated at your location(s)?
Assessor Calculations
Enter zero if appropriate.
9a.
9.
Grand total from page 2
9b.
10a.
10.
Grand total from page 3
10b.
11a.
11.
Grand total from page 4
11b.
12a.
12.
Total cost of Idle Equipment from Form 2698
12b.
X .50
13a.
13.
Total cost of Personal Property Construction in Progress
13b.
Total cost of Cable TV, Utility and Wind Energy Assets from Forms 633, 3589 and 4565
14a.
14.
14b.
15a.
15.
Total cost of cellular site equipment from Form(s) 4452
15b.
TOTAL
The undersigned certifies that he/she is an owner, officer and/or the duly authorized
ASSESSOR'S ADJUSTMENT(S)
agent for the above named taxpayer and that the above summary, with its supporting
EXEMPTION(S)
documents, provides a full and true statement of all tangible personal property
owned or held by the taxpayer at the locations listed above on December 31, 2015.
TRUE CASH VALUE
Signature of Certifier
Date
ASSESSED VALUE (50% of TCV)
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