Form 4001 - Supplier Electronic Filing Application
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1Michigan Department of Treasury
4001 (Rev. 7-09)
Reset Form
Supplier Electronic Filing Application
This form is issued under authority of P.A. 403 of 2000. Filing is mandatory.
Company Name
Application Date
Mailing Address
City
State
Zip Code
FEIN Number
Phone Number
Fax Number
Electronic Filing Contact Person
Contact Person Phone Number
Contact Person Email Address
State Use Only
MFT Account ID:_____________________________
FTP Server User ID:_____________________
IDENTIFY TRANSMISSION FORMAT METHOD
ANSI X.12 813 4030
XML
ANSI X.12 813 4010
OTHER X.12 813 Version: ____________________________
ASCII Flat File
INTERNET FTP SERVER DISCLAIMER: The system is for the use of authorized clients only. Individuals using the
computer network system without authorization, or in excess of their authorization, are subject to having all their activity on
this computer network system monitored and recorded by system personnel. To protect the computer network system
from unauthorized use and to ensure the computer network systems is functioning properly, system administrators monitor
this system. Anyone using this computer network system expressly consents to such monitoring and is advised that if
such monitoring reveals possible conduct of criminal activity, system personnel may provide the evidence of such activity
to law enforcement officers. Access is restricted to authorized users only. Unauthorized access is a violation of state and
federal, civil, and criminal laws.
CERTIFICATION
Authorized Signature
Title
Date
Send applications to:
Michigan Department of Treasury
Special Taxes Division
P.O. Box 30474
Lansing, MI 48909-7974
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