Fillable Form 3067 (Terrapin Networks)

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Form 3067 (Terrapin Networks)

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BROWSE TERRAPIN NETWORKS (MI) FORMS

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Rev 11/23/2015 /Reformatted 1/4/2017
1
City of Manistee
Poverty Exemption Application
I, ________________________________, Petitioner, being the owner and residing at the property that is listed
below as my principal residence, apply for property tax relief under MCL 211.7u of the General Property Tax Act,
Public Act 206 of 1893. The principal residence of persons who, in the judgment of the Township Supervisor or
City Assessor and Board of Review, by reason of poverty are unable to contribute toward the public charges is
eligible for exemption in whole or in part from taxation per MCL 211.7u(1).
In order to be considered complete, this application must 1) be completed in its entirety; 2) include
information regarding all members residing within the house hold; and 3) include all required documentation
as listed within the application. Please write legibly and attach additional pages as necessary.
PERSONAL INFORMATION: Petitioner must list all required personal information.
Property address of Principal Residence:
Daytime Phone Number:
Age of Petitioner:
Marital Status:
Age of Spouse:
Number of Legal Dependents:
Age of Dependents:
Applied for Homestead Property Tax Credit:
Yes No
Amount of Homestead Property Tax Credit:
REAL ESTATE INFORMATION: List the real estate information relating to your principal residence. Be prepared to
provide a legal 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:
ADDITIONAL PROPERT INFORMATION: List information related to any other property you, and or any household
member owns.
Do you own, or are buying, other property?
Yes No If yes, complete the information below.
Amount of Income Earned from other property:
Property Address
Name of Owner(s)
Assessed Value
Amount and
Date of Last Taxes Paid
$
$
$
EMPLOYMENT INFORMATION: List your current employment information.
Name of Employer:
Name of Contact Person:
Address of Employer:
Employer Phone Number:
Rev 11/23/2015 /Reformatted 1/4/2017
2
INCOME SOURCES: List all sources, including but not limited to: salaries, Social Security, rents, pensions, IRA’s
(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.
Source of Income
Monthly or Annual Income (indicate which)
CHECKING, SAVINGS, AND INVESTMENT INFORMATION: List any and all savings owned by all household
members, including but not limited to: checking accounts, savings accounts, postal savings, credit union shares,
certificates of deposit, cash, stocks, bonds, or similar investments.
Name of Financial
Institution or Investments
Current
Interest Rate
Name(s) on
Account
Value of
Investment
MONETARY GIFTS: List all gifts received by all household members given within the last three (3) years.
See Eligibility, Section 7:
Name
Relationship
Item Gifted
Value of Gift
Date Received
LIFE INSURANCE: List all polices held by all household members
Name of Insured
Amount
of Policy
Monthly payment
Policy paid
in full
Name
of Beneficiary
Relationship to
Insured
MOTOR VEHICLE INFORMATION: 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
LIST ALL PERSONS LIVING IN HOUSEHOLD: All persons residing in the residence must be listed.
First and Last Name
Age
Relationship to
Applicant
Place of
Employment
Amount of Monetary Contribution
to Family Income
Rev 11/23/2015 /Reformatted 1/4/2017
3
LIST ALL PERSWONS WITH AN INTERST FROM A LIFE ESTATE/LEASE
First and Last Name
Age
Relationship to
Applicant
Place of
Employment
Amount of Monetary Contribution
to Family Income
PERSONAL DEBT: All personal debt for all household members must be listed
Creditor
Purpose of Debt
Date of Debt
Original Balance
Monthly Payment
Balance Owed
MONTHLY EXPENSE INFORMATION: The amount of monthly expenses related to the principal residence for each
category must be listed. Indicate N/A as necessary.
Heating:
Electric:
Water:
Phone:
Cable:
Food:
Clothing:
Health Insurance:
Garbage:
Daycare:
Car Expense (gas, repair, etc.)
Other (List type):
Other (List type):
Other (List type):
Other (List type):
Other (List type):
Other (List type):
Other (List type):
Other (List type):
Other (List type):
Other (List type):
Other (List type):
Other (List type):
Other (List type):
OTHER ASSETS: List all other assets and their values that are owned or controlled by you or members of your
household. (For example, boats, coin collections, antiques, silver).
Type of Asset
Value
Income Derived from Assets
Owner
Notice: Any willful misstatements or misrepresentations made on this form may constitute perjury, which, under the
law, is a felony punishable by fine or imprisonment.
Rev 11/23/2015 /Reformatted 1/4/2017
4
Notice: Per MCL 211.72(2B), a copy of all household members federal income tax returns, state income tax returns (MI-
10440) and Homestead Property Tax Credit claims (MI-1040CR, 1, 2, 3, or 4) must be attached as proof of income.
Documentation for all income sources including, but not limited to, credits, claims, Social Security income, child support,
alimony income, and all other income sources must be provided at time of application.
PETITIONERS: Do not sign this application until witnessed by the Supervisor, Assessor, Board of Review of Notary Public.
(Must be signed by either the Supervisor, Assessor, Board of Review Member or Notary Public).
STATE OF MICHIGAN
COUNTY OF MANISTEE
I, the undersigned Petitioner, hereby declare that the foregoing information is complete and true and that
neither I, nor any household member residing within the principal residency, have money, income or property
other than mentioned herein.
________________________________ ___________________
Petitioner Signature Date
Subscribes and sworn this ___________ day of _________________, 2017
Assessor Signature:________________________________ Printed Name: __________________________
BOR Member Signature:____________________________ Printed Name: __________________________
Notary Signature:__________________________________ Printed Name: __________________________
My Commission Expires: ___________________________
This application shall be filed after January 2, but before the day prior to the last day of March, July or December
Board of Review to the address below:
Board of Review
c/o Great Lake Assessing
City of Manistee
70 Maple Street
Manistee, MI 49660
231.468.2977
DECISIONS OF THE MARCH BOARD OF REIVEW MAY BE APPEALED IN WRITING TO THE MICHIGAN TAX
TRIBUNAL BY JULY 31 OF THE CURRENT YEAR. JULY OR DECEMBER BOARD OF REVIEW DENIALS MAY BE
APPEALED TO THE MCIHGIAN TAX TRIBUNAL WITHING 30 DAYS OF THE DENIAL. A COPY OF THE BOARD OF
REVIEW DECISISON MUST BE INLCUDED WITH THE FILING.
Michigan Tax Tribunal
P.O. Bo 30232
Lansing, MI 48909
Phone: 517.373.3003
FAX: 517.373.1633
Email: taxtrib@michigan.gov
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Form 3067 (Terrapin Networks)

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Completed 14 July 2020

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