Form 4896 - Michigan Corporate Income Tax Unitary Business Group Affiliates Excluded From The Return Of Standard Taxpayers - 2012

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Michigan Department of Treasury

Attachment 11

4896 (Rev. 03-12)

2012 Michigan Corporate Income Tax Unitary Business Group Affiliates Excluded

from the Return of Standard Taxpayers

Issued under authority of Public Act 38 of 2011.

Federal Employer Identification Number (FEIN)

Designated Member Name

List every C Corporation (or entity taxed as such), insurance company, or financial institution, with or without nexus, for which the “greater than 50%”

ownership test of a Michigan Unitary Business Group (UBG) is satisfied, which is not included on the combined return of standard taxpayers that is supported

by this form. Using the reason codes for exclusion, listed in the instructions, identify in column D why each entity is not included in the combined return. If

any entity listed here is part of a federal consolidated group, attach a copy of U.S. Form 851.

Number From

Reason

Check (X) if

U.S. Form 851

Nexus with

Code for

NAICS Code

(if applicable)

Name

FEIN or TR Number

Exclusion