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Poverty Exemption Affidavit

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Michigan Department of Treasury

4988 (05-12)

Poverty Exemption Affidavit

This form is issued under authority of Public Act 206 of 1893; MCL 211.7u.

INSTRUCTIONS: When completed, this document must accompany a taxpayer’s Application for Poverty Exemption filed

with the supervisor or the board of review of the local unit where the property is located. MCL 211.7u provides for a whole

or partial property tax exemption on the principal residence of an owner of the property by reason of poverty and the

inability to contribute toward the public charges. MCL 211.7u(2)(b) requires proof of eligibility for the exemption be provided

to the board of review by supplying copies of federal and state income tax returns for all persons residing in the principal

residence, including property tax credit returns, or by filing an affidavit for all persons residing in the residence who were not

required to file federal or state income tax returns for the current or preceding tax year.

I, _______________________________________, swear and affirm by my signature below that I

reside in the principal residence that is the subject of this Application for Poverty Exemption and that

for the current tax year and the preceding tax year, I was not required to file a federal or state income

tax return.

Address of Principal Residence: ___________________________________________________

___________________________________________________

_____________________________________________________

_____________________

Signature of Person Making Affidavit

Date

Poverty Exemption Affidavit

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