Form 3976 - Electronic Signature Declaration For Real And Personal Property Statements
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Michigan Department of Treasury
3976 (Rev. 08-13)
Electronic Signature Declaration for Real and Personal Property Statements
Issued under Public Act 267 of 2002. FIling is voluntary.
INSTRUCTIONS: Michigan Compiled Law (MCL) 211.19 allows the use of an electronic signature on a Real Property Statement and on a Personal
Property Statement (Form 632 - L-4175) filed electronically. An individual desiring to use an electronic signature on a Real or Personal Property Statement
must first properly complete this form and submit it to the Assessment and Certification Division of the Michigan Department of Treasury. Upon receipt of
a properly completed Form 3976, 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 a Real or Personal Property Statement electronically. The
PIN expires one year from the date of issuance.
Taxpayer Name
Name and Address (City, State, ZIP Code) of Person Authorized Below to Obtain this Request
Contact E-mail Address
Contact Telephone Number
The State Tax Commission has adopted a procedure for acceptance of electronic signatures by local tax collecting units. This procedure is
provided on the reverse side of this form. The user of this form is strongly urged to read this procedure before completing this form.
THIS FORM IS CONSIDERED CONFIDENTIAL AND INFORMATION ON THIS FORM IS TO BE USED ONLY IN THE ASSESSMENT PROCESS.
DECLARATION
I, ___________________________________________ , being duly sworn, depose and say that each Real Property Statement
containing the personal identification number to be assigned to me by the Assessment and Certification Division, is a true and
complete statement of all real property owned by me in the assessing district for which the statement is made on the date of the
statement. I further depose and say that each Personal Property Statement containing this personal identification number is a true and
correct statement of all tangible personal property owned or held by _____________________________ in the assessing district for
which the statement is made on the 31st day of December immediately preceding the year of the personal property statement.
Must be signed by owner, partner, corporate officer, or a duly authorized agent with attached Power of Attorney, Letter of Authority, etc.
Signed (Must be actual signature)
Title
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
FOR ASSESSMENT AND CERTIFICATION DIVISION USE ONLY
PIN Number
Issuance Code
Date of PIN Issuance
Date of PIN Expiration
Mail the ORIGINAL declaration to:
Michigan Department of Treasury
Assessment and Certification Division
P.O. Box 30790
Lansing, MI 48909-8290
If you have any questions, contact the Michigan Department of Treasury Assessment and Certification Division at (517) 373-0500.
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