TE-SOURCE
Michigan Department of Treasury
3828 (Rev. 05-13)
Application for Air Pollution Control Tax Exemption Certificate
Issued under authority of P.A. 451 of 1994, as amended, Part 59. Filing is mandatory.
General Information. Complete All Boxes.
New
Amend
Transfer Certificate #1
This section pertains to the facility where the air pollution control equipment is located.
PART 1 SOURCE IDENTIFICATION.
1. Company Name (Applicant must be owner of facility)
2. AQD Source ID (SRN)
3. Primary SIC Code
Address (equipment location)
City, State, ZIP Code
4. County
5. Name of Taxing Authority. Select one only.
City of
Township of
Village of
6. Describe the major process or processes of the pollution control equipment at the facility.
7. Enter the total value of requested tax exemption. Indicate whether value is "Estimated" or "Final" by checking the appropriate box.
(If cost is estimated, you must supply the final cost within 90 days of completion of construction.) May apply with estimated costs only if project is
not completed.
Estimated
Final
$
PART 2: TECHNICAL CONTACT/PREPARER. Technical contact should be able to respond to technical questions
concerning this application. Enter Preparer information, if different than Technical Contact.
8. Technical Contact Name
Position/Title
E-mail Address
Telephone Number
Fax Number
9. Preparer Name
Position/Title
Company Name
Telephone Number
Fax Number
Company Mailing Address
E-Mail Address
PART 3: COMPANY REPRESENTATIVE. Name and address for Tax Exemption response. Complete all boxes.
COMPANY REPRESENTATIVE INFORMATION. Name and address for Tax Exemption Response
10. Company Official Name
Position/Title
Street Address
City, State, ZIP Code
E-mail Address
Telephone Number
Fax Number
I certify that all the information contained in this tax exemption application is true and correct to the best of my knowledge.
Signature of Company Official (No authorized agents)
Date
FOR OFFICE USE ONLY
FOR STATE USE ONLY
Reviewed By
Date Received/Date Reviewed
Application Number
LUCI Code