Form 4912 - Michigan Certification Of Exemption For Flow-Through Withholding Payments - 2013
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1Michigan Department of Treasury
4912 (Rev. 05-13)
2013 MICHIGAN Certification of Exemption for Flow-Through Withholding Payments
Issued under authority of Public Act 217 of 2012 and PA 15 of 2013.
Instructions
Neither the member nor the FTE should file this
For purposes of this form, “member” means a Flow-
certificate with the Michigan Department of Treasury
Through Entity’s C Corporation or other Flow-Through Entity
(Treasury).
member. The term excludes non-resident individuals.
A member of a Flow-Through Entity (FTE) may elect not to
Both entities must maintain a copy of this certificate in
be withheld upon under Michigan Compiled Laws (MCL)
their records in accordance with MCL 206.703(16)(d) and
206.703(16). The election is accomplished by the member
Rule 205.4103.
filing this exemption certificate, or any comparable
document containing this information, with the FTE. As
Treasury maintains the right to revoke an exemption
long as an exemption certificate is received by the FTE
certificate if it finds that the member or FTE is not
then it is entirely exempt from the flow-through withholding
abiding by the terms of the certificate or the exemption
(FTW) requirements pertaining to that member for the
requirements as explained above. If an exemption
entire tax year in which the FTE receives the certificate.
certificate is revoked, Treasury will notify the FTE that it
The FTE is exempt no matter when the FTE receives the
must begin to withhold on the member’s distributive share
exemption certificate, so long as the FTE receives the
of taxable income as required under FTW within 60 days
exemption certificate within its tax year.
of that notice.
PArT 1: MEMbEr INForMATIoN
Federal Employer Identification Number (FEIN)
Taxpayer Name
Street Address
City
State
ZIP Code
Authorized Contact Person for Tax Matters
Contact Phone Number
Tax Year End Date of Filer (MM-DD-YYYY)
PArT 2: FloW-THrouGH ENTITy INForMATIoN
Taxpayer Name
FEIN
Street Address
City
State
ZIP Code
Authorized Contact Person for Tax Matters
Contact Phone Number
Tax Year End Date of FTE (MM-DD-YYYY)
PArT 3: CErTIFICATIoN
By signing below, the member certifies:
• It will file the returns required under Part II (Corporate Income Tax) or Part III (FTW) of the Income Tax Act per MCL
206.703(16)(a)(i).
• It will pay or withhold the tax due under Part II (CIT) or Part III (FTW) of the Income Tax Act on the distributive share
of the business income received from any FTE in which it is a member per MCL 206.703(16)(a)(ii).
• It will submit to the taxing jurisdiction of Michigan for purposes of collecting the tax due under Part II (CIT) or Part III
(FTW) of the Income Tax Act and any associated penalty and interest per MCL 206.703(16)(a)(iii).
Signature of Authorized Contact for the Member
Date
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