Form 2748 - Senior Citizen Or Totally And Permanently Disabled Person'S Affi Davit Requesting Special Assessment Deferment
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Michigan Department of Treasury
OFFICE USE ONLY
2748 (Rev. 02-13)
File No.
Senior Citizen or Totally and Permanently Disabled Person’s
Affi davit Requesting Special Assessment Deferment
Issued under authority of Public Act 225 of 1976; MCL 211.764
This is a loan to the property owner by the State of Michigan. A lien will be placed on the property.
The lien will not be removed until the loan has been repaid at the time of sale or transfer of the property.
PART 1: PERSONAL INFORMATION
First Name and Middle Initial
Last Name
Social Security Number
Date of Birth
Spouse’s First Name and Middle Initial (joint return only) Spouse’s Last Name
Spouse’s Social Security Number
Spouse’s Date of Birth
Home Address (number and street or RR#)
City or Town
State
ZIP Code
Home Telephone Number
PART 2: ELIGIBILITY DETERMINATION
Yes
No
1. Are you (a) citizen(s) of the United States? ............................................................................................................
Yes
No
2. Have you been (a) resident(s) of Michigan for fi ve years or more?........................................................................
Yes
No
3. Are you currently and have you been the sole owner(s) of the homestead for fi ve or more years? ......................
Yes
No
4. a. Is there a mortgage or land contract on your homestead? ................................................................................
b. Has the mortgage or land contract holder on your homestead contested to this request for a special
Yes
No
assessment deferment? (A copy of the written consent must be attached.) ...............................................
Yes
No
c. Are you totally and permanently disabled and receiving benefi ts under Social Security? ................................
5. Total household income for the prior calendar year................................................................................................
mm/dd/yyyy
6. When is the next installment payment due on the special assessment? ...............................................................
7. What is the type or purpose of the special assessment?
8.
I (we) declare under penalty of perjury that I (we) qualify for the deferment of special assessments on this homestead as defi ned in
Public Act 225 of 1976, as amended; that I (we) have examined this affi davit, and to the best of my (our) knowledge and belief, it is
true, correct, and complete; and I (we) acknowledge that the amount of the assessment deferred will be subject to an interest rate
of one-half of one percent per month or fraction of a month. I (WE) UNDERSTAND THAT IF THIS DEFERMENT IS AUTHORIZED,
THE STATE WILL PLACE A LIEN ON MY PROPERTY.
Signature
Date
Spouse’s Signature
Date
PART 3: DEFERRED TAX ASSESSMENT COMPUTATION
(Local assessor must complete this section)
9. Original amount of special assessment (must be $300 or more to qualify; attach tax bill) .....................................
10. Amount paid on special assessment by owner ......................................................................................................
11. a. Amount of assessment to be deferred (subtract line 10 from line 9) ................................................................
b. Amount of line 11a which is delinquent (attach tax bill) to:
Local Unit....................................................
County ........................................................
12. Complete legal description of owned and occupied homestead, including local parcel number
13.
I have examined the above affi davit and determined that the amount claimed is correct. The above named applicant(s) is (are)
aware of the one-half of one percent per month or portion of a month interest provision. The consent of the mortgagee or
land contract holder, if applicable, is attached and the requirements of Public Act 225 of 1976, as amended, have been
satisfi ed by the applicant(s).
Assessing Offi cer Signature
County
City, Village, or Township
Federal Employer I.D. Number
Assessor Telephone Number
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