Fill and Sign the Connecticut Assignment Form

Reset Form Michigan Department of Treasury 4753 (Rev. 6-09) Commercial Rehabilitation Exemption Certification For Qualified Retail Food Establishments Issued under authority of Public Act 210 of 2005. After completing Part 1, this Qualified Retail Food Establishment Certification form must be submitted by the applicant to the local governmental unit (LGU) clerk, along with the Application for Commercial Rehabilitation Exemption Certificate and supporting documents. The LGU shall complete and certify Part 2 of this form. For assistance in determining the property’s qualified LGU designation under A or B, visit www.michigan.gov/propertytaxexemptions and click on Commercial Rehabilitation Act. If the LGU certifies the requirements of Part 2, the property may qualify for the exemption and this form and a copy of the “underserved area” description must be submitted to the Michigan Department of Agriculture at the address listed at the bottom of this form. The Michigan Department of Agriculture will certify Part 3 of this form and return it to the LGU for submission with the completed application to the State Tax Commission. PART 1: OWNER / APPLICANT INFORMATION Applicant (Company) Name (applicant must be the owner of the facility) Facility’s Street Address City State Name of City, Township, or Village (taxing authority) County School District City Township ZIP Code Village PART 2: LOCAL GOVERNMENT UNIT (LGU) CERTIFICATION Certify one of the following: A. The property is located in a qualified local governmental unit as defined in Section 2 of the Obsolete Property Rehabilitation Act (PA 146 of 2000, as amended), OR B. The property is located in a qualified local governmental unit that is designated as rural as defined by the United States census bureau. Certify the following: The property was used as residential, commercial, or industrial property as allowed and conducted under the applicable zoning ordinance for the immediately preceding 30 years. LGU Representative Name LGU Representative’s Signature LGU Address Title Date PART 3: MICHIGAN DEPARTMENT OF AGRICULTURE CERTIFICATION Certify one of the following: The property is located in an underserved area. The property is NOT located in an underserved area. Explain: Authorization of MI Dept of Agriculture Representative Michigan Department of Agriculture Attn: Agriculture Development Division PO Box 30017 Lansing, Michigan 48909 Signature of Authorized MI Department of Agriculture Representative Date