Form 4435 - 2014 Electronic Signature Declaration For Annual Property Reports For State Assessed Telephone, Railroad And Car Line Entities

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Michigan Department of Treasury
4435 (Rev. 08-13)
2014 Electronic Signature Declaration for Annual Property Reports
For State Assessed Telephone, Railroad and Car Line Entities
Issued under authority of Public Act 282 of 1905, as amended.
INSTRUCTIONS: Any state assessed entity desiring to use an electronic signature on an Annual Property Report or to gain access to an individual
secure online account, must properly complete this form and mail it to the Assessment and Certification Division (mailing address at bottom of form).
Upon receipt of a properly completed form, the Assessment and Certification Division will issue a personal identification number (PIN) by conventional
mail to the person who signs this form. This PIN may then be used in lieu of an actual signature when filing an Annual Property Report electronically.
Taxpayer Company Name on Report
Name and address (City, State, ZIP Code) of Person Authorized Below to Obtain this Request
Contact E-mail Address
Contact Telephone Number
THIS FORM IS CONFIDENTIAL AND INFORMATION ON THIS FORM IS TO BE USED ONLY IN THE ASSESSMENT PROCESS.
TYPE OF REPORTING ENTITY:
Telephone
Railroad
Rail Car Line
DECLARATION
I, _____________________________ , being duly sworn, depose and say that each Annual Property Report containing the personal
(print legibly)
identification number to be assigned to me by the Assessment and Certification Division, is a true and complete statement of all prop-
erty, both real and personal, owned and/or used for state assessed purposes by the within mentioned taxpayer for the reporting period
covered by the report, and that all data provided for the purposes of determining eligibility for, and calculating credits available for the
reporting period is true and accurate to the best of my knowledge.
In addition, by affixing my signature below, I do hereby affirm that I am a person duly authorized to procure a confidential personal
identification number on behalf of the stated taxpayer, by virtue of the authority granted to me as President Secretary, Superintendent,
Chief Officer, Owner, or duly authorized agent with attached Power of Attorney, Letter of Authority, etc.
Signature (must be actual signature) and Title
Date
REQUIRED NOTARIZATION
Subscribed and sworn to before me this ______________________________ day of ___________________________, 20____________________.
Notary Public, State of
County
ss
Signature of Notary Public
My Commission Expires
Printed Name of Notary Public
Acting in the County of
ASSESSMENT AND CERTIFICATION DIVISION USE ONLY
Company Parcel Number
PIN Number
Date of PIN Issuance
- 00 - 00 - 00 - 000 -
If you have any questions, visit or contact the Assessment and Certification Division at
(517) 241-4338.
Mail this original declaration to:
Michigan Department of Treasury
Assessment and Certification Division
P.O. Box 30790
Lansing, MI 48909-8290

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