Form 1012 - Application For Industrial Facilities Tax Exemption Certificate Page 2
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41012, Page 2
APPLICANT CERTIFICATION - complete all boxes.
The undersigned, authorized officer of the company making this application certifies that, to the best of his/her knowledge, no information contained
herein or in the attachments hereto is false in any way and that all are truly descriptive of the industrial property for which this application is being
submitted.
It is further certified that the undersigned is familiar with the provisions of P.A. 198 of 1974, as amended, being Sections 207.551 to 207.572, inclusive, of
the Michigan Compiled Laws; and to the best of his/her knowledge and belief, (s)he has complied or will be able to comply with all of the requirements
thereof which are prerequisite to the approval of the application by the local unit of government and the issuance of an Industrial Facilities Exemption
Certificate by the State Tax Commission.
13a. Preparer Name
13b. Telephone Number
13c. Fax Number
13d. E-mail Address
14a. Name of Contact Person
14b. Telephone Number
14c. Fax Number
14d. E-mail Address
15a. Name of Company Officer (No Authorized Agents)
15b. Signature of Company Officer (No Authorized Agents)
15c. Fax Number
15d. Date
15f. Telephone Number
15g. E-mail Address
15e. Mailing Address (Street, CIty, State, ZIP Code)
LOCAL GOVERNMENT ACTION & CERTIFICATION - complete all boxes.
This section must be completed by the clerk of the local governing unit before submitting application to the State Tax Commission. Check items on file
at the Local Unit and those included with the submittal.
16b. The State Tax Commission Requires the following documents be filed for an
16. Action taken by local government unit
administratively complete application:
Abatement Approved for _______ Yrs Real (1-12), _____ Yrs Pers (1-12)
Check or Indicate N/A if Not Applicable
1. Original Application plus attachments, and one complete copy
After Completion
Yes
No
2. Resolution establishing district
Denied (Include Resolution Denying)
3. Resolution approving/denying application.
4. Letter of Agreement (Signed by local unit and applicant)
16a. Documents Required to be on file with the Local Unit
5. Affidavit of Fees (Signed by local unit and applicant)
Check or Indicate N/A if Not Applicable
6. Building Permit for real improvements if project has already begun
1. Notice to the public prior to hearing establishing a district.
7. Equipment List with dates of beginning of installation
2. Notice to taxing authorities of opportunity for a hearing.
8. Form 3222 (if applicable)
3. List of taxing authorities notified for district and application action.
9. Speculative building resolution and affidavits (if applicable)
4. Lease Agreement showing applicants tax liability.
16c. LUCI Code
16d. School Code
17. Name of Local Government Body
18. Date of Resolution Approving/Denying this Application
Attached hereto is an original and one copy of the application and all documents listed in 16b. I also certify that all documents listed in 16a are
on file at the local unit for inspection at any time.
19a. Signature of Clerk
19b. Name of Clerk
19c. E-mail Address
19d. Clerk's Mailing Address (Street, City, State, ZIP Code)
19e. Telephone Number
19f. Fax Number
State Tax Commission Rule Number 57: Complete applications approved by the local unit and received by the State Tax Commission by October 31
each year will be acted upon by December 31. Applications received after October 31 may be acted upon in the following year.
Local Unit: Mail one original and one copy of the completed application and all required attachments to:
State Tax Commission
Michigan Department of Treasury
P.O. Box 30471
Lansing, MI 48909-7971
(For guaranteed receipt by the STC, it is recommended that applications are sent by certified mail.)
STC USE ONLY
LUCI Code
Begin Date Real
Begin Date Personal
End Date Real
End Date Personal
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