Michigan Department of Treasury
5737 (01-21), Page 1 of 4
Application for MCL 211.7u Poverty Exemption
This form is issued under the authority of the General Property Tax Act, Public Act 206 of 1893, MCL 211.7u.
MCL 211.7u of the General Property Tax Act, Public Act 206 of 1893, provides a property tax exemption for the principal
residence of persons who, by reason of poverty, are unable to contribute toward the public charges. This application is to be
used to apply for the exemption and must be led with the Board of Review where the property is located. This application
may be submitted to the city or township the property is located in each year on or after January 1.
To be considered complete, this application must: 1) be completed in its entirety, 2) include information regarding all
members residing within the household, and 3) include all required documentation as listed within the application. Please
write legibly and attach additional pages as necessary.
PART 1: PERSONAL INFORMATION — Petitioner must list all required personal information.
Petitioner’s Name Daytime Phone Number
Age of Petitioner Marital Status Age of Spouse Number of Legal Dependents
Property Address of Principal Residence City State ZIP Code
Check if applied for Homestead Property Tax Credit
Amount of Homestead Property Tax Credit
List the real estate information related to your principal residence. Be prepared to provide a deed, land contract or other
evidence of ownership of the property at the Board of Review meeting.
Property Parcel Code Number Name of Mortgage Company
Unpaid Balance Owed on Principal Residence Monthly Payment Length of Time at this Residence
Property Description
List information related to any other property owned by you or any member residing in the household.
Check if you own, or are buying, other property. If checked, complete the
information below.
Amount of Income Earned from other Property
Property Address City State ZIP Code
Name of Owner(s) Assessed Value Date of Last Taxes Paid Amount of Taxes Paid
Property Address City State ZIP Code
Name of Owner(s) Assessed Value Date of Last Taxes Paid Amount of Taxes Paid
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PART 4: EMPLOYMENT INFORMATION — List your current employment information.
Name of Employer
Address of Employer City State ZIP Code
Contact Person Employer Telephone Number
List all income sources, including but not limited to: salaries, Social Security, rents, pensions, IRAs (individual retirement
accounts), unemployment compensation, disability, government pensions, worker’s compensation, dividends, claims and
judgments from lawsuits, alimony, child support, friend or family contribution, reverse mortgage, or any other source of
income, for all persons residing at the property.
Source of Income
Monthly or Annual Income
(indicate which)
List any and all savings owned by all household members, including but not limited to: checking accounts, savings
accounts, postal savings, credit union shares, certicates of deposit, cash, stocks, bonds, or similar investments, for all
persons residing at the property.
Name of Financial Institution
or Investments
on Deposit
Interest Rate
Name on Account
Value of
PART 7: LIFE INSURANCE — List all policies held by all household members.
Name of Insured
Amount of
Policy Paid in
Full Name of Beneciary
Relationship to
All motor vehicles (including motorcycles, motor homes, camper trailers, etc.) held or owned by any person residing
within the household must be listed.
Make Year Monthly Payment Balance Owed
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PART 9: HOUSEHOLD OCCUPANTS — List all persons living in the household.
First and Last Name Age
to Applicant Place of Employment
$ Contribution to
Family Income
PART 10: PERSONAL DEBT — List all personal debt for all household members.
Creditor Purpose of Debt
of Debt Original Balance Monthly Payment Balance Owed
The amount of monthly expenses related to the principal residence for each category must be listed. Indicate N/A as
Heating Electric Water Phone
Cable Food Clothing Health Insurance
Garbage Daycare Car Expense (gas, repair, etc.)
Other (type and amount) Other (type and amount) Other (type and amount)
Other (type and amount) Other (type and amount) Other (type and amount)
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NOTICE: Per MCL 211.7u(2)(b), federal and state income tax returns for all persons residing in the principal residence,
including any property tax credit returns, led in the immediately preceding year or in the current year must be submitted
with this application. Federal and state income tax returns are not required for a person residing in the principal residence
if that person was not required to le a federal or state income tax return in the tax year in which the exemption under this
section is claimed or in the immediately preceding tax year.
The governing body of the local assessing unit shall determine and make available to the public the policy and guidelines
used for the granting of exemptions under MCL 211.7u. In order to be eligible for the exemption, the applicant must meet
the federal poverty guidelines published in the prior calendar year in the Federal Register by the United States Department
of Health and Human Services under its authority to revise the poverty line under 42 USC 9902, or alternative guidelines
adopted by the governing body of the local assessing unit so long as the alternative guidelines do not provide income
eligibility requirements less than the federal guidelines. The policy and guidelines must include, but are not limited to,
the specic income and asset levels of the claimant and total household income and assets. The combined assets of all
persons must not exceed the limits set forth in the guidelines adopted by the local assessing unit.
The applicant has reviewed the applicable policy and guidelines adopted by the city or township, including the
specic income and asset levels of the claimant and total household income and assets.
I hereby certify to the best of my knowledge that the information provided in this form is complete, accurate and I am
eligible for the exemption from property taxes pursuant to Michigan Compiled Law, Section 211.7u.
Printed Name Signature Date
This application shall be led after January 1, but before the day prior to the last day of the local unit’s December
Board of Review.
Decision of the March Board of Review may be appealed by petition to the Michigan Tax Tribunal by July 31 of
the current year. A July or December Board of Review decision may be appealed to the Michigan Tax Tribunal by
petition within 35 days of decision. A copy of the Board of Review decision must be included with the petition.
Michigan Tax Tribunal
PO Box 30232
Lansing MI 48909
Phone: 517-335-9760
E-mail: taxtrib@michigan.gov