Form 4796 - Forfeiture And Foreclosure Database User Id Request

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Michigan Department of Treasury
4796 (04-11)
Forfeiture and Foreclosure Database User ID Request
Issued under the authority of P.A. 206 of 1893.
INSTRUCTIONS: Use one form for each ID requested. Failure to provide complete information for all fields may result in an inability
to process your request. User ID requests are for vendors who work with tax-delinquent real property as part of their official
duties. Mail the completed request to Foreclosure Services, Michigan Department of Treasury, PO Box 30760, Lansing MI 48909 or fax
it to (517) 335-3264. When access is assigned, notification will be sent to the applicant’s e-mail address listed below.
(must complete all fields)
APPLICANT INFORMATION
Applicant Full Name (Last, First, Middle Initial)
Mailing Address (Address, City, State, ZIP Code)
Applicant Telephone Number
County/Local Unit
Applicant Title
Applicant E-mail Address
APPLICANT AGREEMENT/SIGNATURE
I have reviewed and agree with the Michigan Information Technology Security and the Acceptable Use policies. I understand that my access to this
database may be withdrawn if it is discovered that I am using such information for purposes other than those intended.
Applicant Signature
Date
COUNTY TREASURER AGREEMENT/SIGNATURE
I certify that the above applicant is an employee whose official duties require access to forfeiture data for the County. I agree to notify the Department of
Treasury of any violations of this agreement or when the applicant is no longer involved with real property forfeitures.
County Treasurer Signature
Date
Print Name
Title
DEPARTMENT OF TREASURY USE ONLY
Approved by
User ID Assigned
Date Approved

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