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Michigan Department of Treasury
Applicant Name
3222 (Rev. 6-05)
Fiscal Statement (to be completed by local unit)
YES
NO
Is this project:
Real Property?
Personal Property?
Both Real and Personal Property - New Facility?
Both Real and Personal Property - Rehabilitation Facility?
Both New and Replacement Facility?
Estimated Project Investment (not assessed value):
Real Property
Personal Property
Total
YES
NO
REMARKS
1.
A. Has the proper local authority reviewed the
plan?
B. Is the project located in a certified industrial
park?
C. Is this a renovation or expansion of an existing
building?
2.
Will this project require improvement of your road
service?
3.
Will this project require improvement of your
sanitary sewer services?
4.
Will this project require improvement of your storm
sewer services?
5.
Will this project require improvement of your water
services?
6.
Will
this
project
require
additional
police
personnel, police equipment or a need for new
police building expansion?
7.
Will this project require the need for additional fire
personnel, additional or specialized fire equipment
or the need for a new fire building?
8.
Will this project require other costs?
9.
Are costs of infrastructure elements to be provided
through Local Development Finance Authority or
Tax Increment Finance Authority Bonds?
If you answered yes to any of questions 2 through 8, the appropriate sections of the Supplement to Fiscal Statement form
must be completed and accompany the IFT application. Call (517) 373-3272 to obtain that form.
LOCAL UNIT CERTIFICATION
This is to certify that the following has been provided as accurately as possible.
Signature
Name and Title of Local Governmental Unit Official