Form 628 - Notice By Owner Of Property Incorrectly Reported Or Omitted From Assessment Roll

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Michigan Department of Treasury
628, Formerly L-4155 (Rev. 10-08)
Notice by Owner of Property Incorrectly Reported
File Number
or Omitted From Assessment Roll
Assessment Unit Number
This form is issued under authority of Section 211.154, MCL.
INSTRUCTIONS: This side is to be completed by the owner.
Name of Property Owner(s)
Telephone Number
Owner's Address (Number, Street, City, State and ZIP Code)
Email Address
Name of Agent
Telephone Number
Agent's Address (Number, Street, City, State and ZIP Code)
Email Address
County Where Property is Located
City or Township or Village and Township
School District
Intermediate School District
Community College District
Property Index Number/Parcel Code (or enter property description below)
Property Classification
Real Residential
Real Agricultural
Personal Industrial
Personal Residential
Real Industrial
Real Developmental
Personal Commercial
Personal Agricultural
Special Roll (PA 198, PA 255, PA 189)
Real Commercial
Real Timber-cutover
Personal Utility
Property Description
Assessed Value
Taxable Value
Year(s) For Which
Assessed Value on
Requested Assessed
Year(s) For Which
Taxable Value on
Requested Taxable
Notice Was Given
Assessment Roll
Notice Was Given
Assessment Roll
Did the property covered by this notice change ownership during the time period starting with the earliest year for which a change is being requested
up to the present?
If yes, give date.
Signature of Owner or Agent
REASON FOR THIS NOTICE: This form will not be processed if the information/documentation requested in
STC Date Stamp
this space is not provided. Attach relevant supporting information. Include a copy of the timely-filed personal
property statement and the amended personal property statement. Provide a record card or other
documentation showing that omitted real property was not previously included in the assessment.
FILING INSTRUCTIONS: When you have completed this side of the form, send or carry one copy to your local assessor, who will complete the reverse
side and file the fully completed form with the State Tax Commission (STC). The STC's jurisdiction under MCL 211.154 is limited to correcting
assessments for the current assessment year (the year of discovery and disclosure to the STC) and two immediately preceding years. You may
immediately submit a second copy of this form, with this side completed, to the STC at the address on the back of this form. Your failure to do so by
December 31 of the current calendar year may affect the STC's jurisdiction to consider all of the assessment years that you have included on this form.
Continued on page 2.


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