Michigan Department of Treasury
5076 (Rev. 11-16)
Parcel Number
2017
Afdavit to Claim Small Business Tax Exemption Under MCL 211.9o
Notice: Questions regarding this form should be directed to the assessor of the city or township where the personal property is located. This form was issued under
the authority of Public Act 206 of 1893. This form must be led annually by the owner or the owner’s authorized agent.
Name and Address of Owner
To claim an exemption, this
Afdavit must be received by the
Assessor of the local unit where
the personal property is located
no later than February 10, 2017
(postmarked is acceptable).
IMPORTANT INFORMATION: This afdavit will exempt property owned only by the entity ling the afdavit. If personal property is leased to or used by
an entity other than the property’s owner, the owner of that personal property must le the afdavit for that property, not the lessee or the user. The owner
may le the afdavit and claim the exemption only if the True Cash Value of all of the commercial or industrial personal property located within the city or
township that is owned by, leased to, or in the possession of the owner or a related entity was less than $80,000 on December 31, 2016.
Name of Local Unit of Government
City Township
List all addresses where Personal Property is located within the City or Township.
(may attach additional sheets)
Names of Owners or Partners (If sole Proprietorship or Partnership)
County Owner Telephone Number Legal Name of Owner, if different from above
Assumed Names Used by Legal Entity, if any Description of Owner’s Business Activity
Check only one:
Sole Proprietorship Limited Liability Co. MI ID# Corporation MI ID# Partnership
Name and Telephone Number of Person in Charge of Personal Property Records Address where Personal Property Records are Kept
Names of all other businesses having personal property, including any leasehold improvements assessed as personal
property at the locations included in this afdavit. (attach additional sheets as necessary)
Date Business Began in Local Tax Collecting
Unit
The undersigned certies that:
1. I am the owner of the commercial personal property and industrial personal property being claimed as exempt or I am the duly authorized agent.
2. The True Cash Value of all the Personal Property, as dened by MCL 211.9o located within the city or township indicated above, that is owned by, leased to, or in
the possession of the owner or related entity was less than $80,000 on December 31, 2016.
3. Below are the procedures used to determine that the True Cash Value of the Eligible Personal Property was less than $80,000 on December 31, 2016:
a) The determination of True Cash Value was based on the State Tax Commission’s recommended valuation procedures
as set forth on Form 632, Personal Property Statement (L-4175). Attach an explanation of the method used if your answer
is NO
.......................................................................................................................................................................................
Yes No
b) The determination of True Cash Value includes all assessable personal property, located within the city or township listed
on this Afdavit that is owned by, leased to, or in the possession of the owner or related entity. This shall include all trade
xtures and may include leasehold improvements not assessed as real property.
Attach an explanation if not all personal
property is included ..................................................................................................................................................................
Yes No N/A
I hereby certify that the information contained within, and attached to, this Afdavit provides a full and true statement of all personal property owned,
leased, or in the possession of the owner or related entity on December 31, 2016.
Printed Name Signature Date
Indicate which:
Sole Proprietor Partner Ofcer Managing Member Agent (attach letter of authority)
Trade Fixtures: Items of property that have been attached to real estate by a tenant to facilitate the tenant’s use of the property for business purposes
and which are both capable of being removed and are removable by the tenant under the terms of the lease. Examples of trade xtures are certain costs
related to telephone and security systems and most signs.
Leasehold Improvements: Land improvements, such as paving and landscaping, and improvements made by a tenant to structures owned by the
landlord. Leasehold improvements are characterized by the fact that they cannot be removed for use elsewhere because they will be destroyed by
removal. Leasehold improvements may be assessed as real property to the owner of the real property or may be assessed as personal property to the
tenant. The State Tax Commission has directed that commencing in 2017 all Leasehold improvement installations in 2016, or later, must be valued as
improvements made to the leased real property.
Additional information can be located in MCL 211.9o and State Tax Commission Bulletin 11 of 2013.
