B
PARCEL: ______________________________
NAME: ___________________________________
TOWNSHIP OF CLAY
ST CLAIR COUNTY
POVERTY/HARDSHIP EXEMPTION FORM-FOR TAX YEAR 2021
|APPLICATION |
In order to be considered, this application must be completed in its entirety, regarding all members residing within the household and must include all required documentation as listed within the application. Please attach additional pages if necessary and submit to the Assessing Department.
APPOINTMENTS ARE ONLY REQUIRED IF YOU WISH TO APPEAR IN PERSON OR WISH TO HAVE A REPRESENTATIVE APPEAR ON YOUR BEHALF. (A letter of authority is required for a representative)
|B. STATEMENT |
I _________________________________, being the owner and residing at the property listed below as my principle residence, apply for property tax relief under MCL 211.7u, as amended of the General Property Tax Act (The principal residence of persons who, in the judgment of the 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 under this act)
|C. PERSONAL INFORMATION |
Name of Applicant: ___________________________________________________________
Address of Principle Residence_________________________________________________
Daytime phone number: _______________________Evening; _________________________
Alternate contact information: ___________________________________________________
Age of Petitioner: _________________Marital Status: ____________
Name of Spouse: _______________________________________Age of spouse_________
Applied for Homestead property credit? Yes__________No____________
Amount of Homestead property credit: _____________________________
Page 3
|D. EMPLOYMENT |
Applicant Status
Employed: ( ) Full-time ( ) Part-time Employer_______________________
Date of Hire: ________________________ Occupation: _____________________
( ) Retired-Date: _____________________ Employer ______________________
( ) Laid-off: Date last worked ___________ Employer ______________________
Possible return date __________________
( ) Not working – How long _____________ Reason: _________________________
_______________________________________________________________________________________
________________________________________________________________________________________
Spouse or Co-Owner Status
Employed: ( ) Full-time ( ) Part-time Employer_______________________
Date of Hire: _______________________ Occupation: _____________________
( ) Retired-Date: ____________________ Employer _______________________
( ) Laid-off: Date last worked __________ Employer _______________________
Possible return date _________________
( ) Not working – How long __________ Reason: _________________________
________________________________________________________________________________________
________________________________________________________________________________________
Resident Information
List ALL PEOPLE, not listed above, living in your household. (Attach additional sheet if necessary)
| |1 |2 |3 |4 |5 |
|Full Name | | | | | |
|Age | | | | | |
|Relationship | | | | | |
|Dependent |Yes No |Yes No |Yes No |Yes No |Yes No |
|Occupation | | | | | |
|Annual Income | | | | | |
|Do they contribute to | | | | | |
|household income? | | | | | |
| |Yes No |Yes No |Yes No |Yes No |Yes No |
| | | | | | |
Page 4
|E. PROPERTY |
Are you and/or your spouse the sole owners of the property? Yes___No__
If no, list other owners___________________________________________________________
When did you and/or our spouse purchase this homestead? _____________________________
Is the home paid in full? Yes_____________ No______________
If no, balance & years remaining on this Mortgage/Land Contract: yrs.: ___________$__________
Name of Mortgage company_______________________________________________________
What is your monthly payment? ____________ Includes taxes? Yes_________ No___________
Do you owe any delinquent mortgage payments? Yes_________ No_____________
If yes, please list the year(s) and amount(s) __________________________________
Do you owe any delinquent Taxes? Yes__________ No___________
If yes, please list the year (s) and amount (s) __________________________________
Have any improvements, changes or additions been made to the property in the last two (2) years?
Yes _______ No_________ If yes, please explain ____________________________________
_____________________________________________________________________________
Are there any changes or additions that need to be made to the property? Yes_______ No_______
If yes, please explain _____________________________________________________________
______________________________________________________________________________
Do you, your spouse, or any other person residing in the homestead have a financial interest in other real estate? If yes, please provide the following information concerning that financial interest.
|Location-City & State |Tax I. D. # of Property |Value of Property |Amount of Equity |
| | |$ |$ |
| | |$ |$ |
| | |$ |$ |
What are your current assets in addition to the real estate noted previously?
Cash $_____________________________
Checking Accounts $_____________________________
Saving Accounts $_____________________________
CDs, Money Markets $_____________________________
Stocks/Bonds/Treasury Bills $_____________________________
Insurance Policy (surrender-cash value) $_____________________________
Retirement Accounts $_____________________________
Personal Property (i.e. Jewelry, coin collection, etc.) $_________________________________
Other – (please explain) $_____________________________
Page 5
List ALL motor vehicles in household (whether paid in full or not) including cars, trucks, and recreational vehicles i.e.: boats, motorcycles, motor homes, travel trailers, jet skis, snow mobiles, ATV’s, etc. Use additional pages if necessary.
|VEHICLES: |MILEAGE |DATE |BOUGHT |PURCHASE |BALANCED |
|YEAR/MAKE/MODEL | |ACQUIRED |OR LEASED |PRICE |OWED |
|1 | | | | | |
|2 | | | | | |
|3 | | | | | |
|Recreation Vehicles | | | | | |
|1 | | | | | |
|2 | | | | | |
|H. INCOME & TOTAL HOUSEHOLD RESOURCES |
For the items below, enter the amount on a YEARLY basis (documentation must be provided)
• Wages, salaries, tips, (attach W-2) $____________
• Social Security or supplemental (SSI) $____________
• Retirement pension, IRA, Annuity $____________
• Alimony and/or child support $____________
• Unemployment compensation $____________
• Workers compensation and/or disability $____________
• Interest and dividend income $____________
• DHS benefits (do not include food) $____________
• Gifts of cash or goods, winnings, awards $____________
• Inheritance or insurance proceeds $____________
• Other $____________
TOTAL $____________
• If you share or have shared your dwelling with others who helped pay rent, property taxes, and/or other expense, use the chart below to show their share of expenses.
A B C D E
Name Relationship Months lived amount paid amount paid
(first, last) to you in your home rent or mortgage other expenses
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
Total of all additional household resources paid for by others: $_____________________
Page 6
Has your income significantly changed in the last year? Yes_______No____
If yes, please explain_______________________________________________________________
________________________________________________________________________________________________________________________________________________________________
Has anyone in the household sold or given away interest in any property in the last 12 months? If so, please provide complete address, date sold and sale price __________________________________
________________________________________________________________________________
|EXPENSE INFORMATION |
Please list all sources of household expenses on a YEARLY AND MONTHLY basis.
| |$ MONTHLY |$ YEARLY |
|House Payment | | |
|Association/Condo Fees | | |
|Taxes on Primary Residence | | |
|Taxes on other property | | |
|Special Assessment | | |
|Home/Auto Insurance | | |
|Phone | | |
|Water | | |
|Electric | | |
|Gas (Heating) | | |
|Food | | |
|Other | | |
|Other | | |
|TOTALS | | |
Have your expenses significantly changed in the last year? Yes___ No___
If yes, please explain_______________________________________________________
________________________________________________________________________
________________________________________________________________________
How did you meet those expenses that you did not have income to cover? (loan, savings, credit card)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Page 7
|J. APPLICANT CERTIFICATION AND AFFIDAVIT |
Please initial EACH application statement:
______ I/We understand that the statements contained in this application are true to the best of my/our knowledge.
______ I/We also understand that this application will be denied or revoked if the information contained is found to be false or incomplete.
______ I/We understand this application for exemption is for the tax year of 2021.
______ I/We have received a copy of and understand the hardship income/asset guidelines.
______ I/We certify that I/We did _______ or did not ______ file a State or Federal Income Tax Return (1040 or MI 1040) or Michigan Homestead Property Tax Credit (MI-CR) for the year__________.
______ I/We hereby authorize the Township of Clay Assessor to verify and or obtain information from any creditor, financial institution, government agency, insurance company or any other organization necessary for the purpose of this application of poverty exemption for the tax year of 2021
The undersigned disposes and says that the statements in the foregoing application are true and that he/she/they have no monetary assets, income or property other than mentioned herein. Any willful misstatements or misrepresentations made on this form may constitute perjury, which under the law, is a felony punishable by fine or imprisonment.
Applicant Signature __________________________________ Date: ______________________
Spouse Signature ___________________________________ Date: _____________________
Name of Preparer if other than applicant: ___________________________________________
Attach letter of Authority
DECISIONS OF THE MARCH BOARD OF REVIEW MAY BE APPEALED BY PETITION TO THE MICHIGAN
TAX TRIBUNAL BY JULY 31 OF THE CURRENT YEAR. JULY OR DECEMBER BOARD OF
REVIEW DECISIONS MAY BE APPEALED TO MICHIGAN TAX TRIBUNAL BY PETITION WITHIN
35 DAYS OF THE DENIAL. A COPY OF THE BOARD OF REVIEW DECISION MUST BE
INCLUDED WITH THE PETITION.
Michigan Tax Tribunal
PO Box 30232
Lansing MI 48909
517-373-4400
taxtrib@
Page 8
|K. BOARD OF REVIEW USE ONLY |
DETERMINATION BY THE BOARD OF REVIEW DATE: _______________
DENIED_________ APPROVIED____________
ASSESSEMENT CHANGED TO: ____________________
TAXABLE VALUE CHANGED TO: ___________________
CHAIRPERSON____________ SECOND MEMBER__________
THIRD MEMBER ___________ SUPERVISOR______________
Comments:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
DECISIONS OF THE MARCH BOARD OF REVIEW MAY BE APPEALED BY PETITION TO THE MICHIGAN
TAX TRIBUNAL BY JULY 31 OF THE CURRENT YEAR. JULY OR DECEMBER BOARD OF
REVIEW DECISIONS MAY BE APPEALED TO MICHIGAN TAX TRIBUNAL BY PETITION WITHIN
35 DAYS OF THE DENIAL. A COPY OF THE BOARD OF REVIEW DECISION MUST BE
INCLUDED WITH THE PETITION.
Michigan Tax Tribunal
PO Box 30232
Lansing MI 48909
517-373-4400
taxtrib@
Page 9
TOWNSHIP OF CLAY
REQUIREMENTS FOR APPLICATION REQUESTING
HARDSHIP/POVERTY EXEMPTION
CONSIDERATION FOR YEAR 2021
1. All applicants must obtain the proper application form from the Assessor’s office.
2. All applicants MUST submit the following to be reviewed. Do not submit originals of supporting documents as we must keep these for our records. If the application is incomplete or has missing documents, it may be considered ineligible and/or denied for the exemption.
A. Federal Income Tax returns, for applicant and all occupants of the household last years and current years if available. (1040/1040a) IF APPLICABLE
B. Michigan Homestead Property Tax Credit form. (MI-1049/MI-1040CR) IF APPLICABLE
C. Statement of Social Services Administration and/or Michigan Social Services income
D. A copy of State of Michigan issued driver’s license or identification card
E. Page 7 **Expense/Debt Information*** SUPPORTING DOCUMENTATION MUST BE PROVIDED
F. Affidavit TREASURY FORM 4988 to be filed for APPLICANT and ALL PERSONS residing in the residence who were not required to file Federal or State income tax returns in the current year or in the immediately preceding year.
Poverty/Hardship Exemption as defined by the Michigan Complied Laws is as follows:
Sec 211.7u: The homestead of persons who in the judgment of the Board of Review, by reason of Poverty are unable to contribute towards the public charges is eligible for exemption in whole or in part from taxation under this act. This section does not apply to the property of a corporation.
PLEASE BE AWARE THAT AS AN APPLICANT FOR POVERTY EXEMPTION, YOU MUST ALSO COMPLY WITH THE FOLLOWING SECTION OF THE MICHIGAN COMPILED LAWS:
Section 211.118: PERJURY: ANY PERSON, WHO, UNDER ANY OF THE PROCEEDING REQUIRED OR PERMITTED BY THIS ACT SHALL WILLFULLY SWEAR FALSELY, WILL BE GUILTY OF PERJURY AND SUBJECT TO ITS PENALTIES.
Section 211.119: WILLFUL NEGLECT: PENALTY-PERSON WHO WILLFULLY NEGLECTS OR REFUSES TO PERFORM A DUTY IMPOSED UPON THAT PERSON BY THIS ACT, WHEN NO OTHER PROVISION IS MADE IN THIS ACT, IS GUILTY OF A MISDEMEANOR, PUNISHABLE BY IMPRISONMENT FOR NOT MORE THAN 6 MONTHS OR A FINE OF NOT MORE THAN $300.00 AND IS LIABLE TO A PERSON INJURED TO THE FULL EXTENT OF THE INJURY SUSTAINED.
IMPORTANT NOTE: PA 390 of 1994 states that the poverty exemption guidelines established by the governing body of the local assessing unit SHALL also include asset level test. An asset test means the amount of cash, fixed assets or other property that could be used, or converted to cash for use in the payment of property taxes. The asset test should calculate a maximum amount permitted and all other assets above that amount should be considered as available.
Page 1
FEDERAL POVERTY GUIDELINES FOR 2021 ASSESSMENTS
Following are the federal guidelines provided by the US Department of Health and Human services for use in setting poverty exemption guidelines for 2021 assessments. Issued by the Michigan Department of Treasury in Bulletin 17 of 2020.
|SIZE OF FAMILY UNIT |POVERTY GUIDELINES |
|1 |$ 12,760 |
|2 |$ 17,240 |
|3 |$ 21,270 |
|4 |$ 26,200 |
|5 |$ 30,680 |
|6 |$ 35,160 |
|7 |$ 36,640 |
|8 |$ 44,120 |
|For each additional person |$ 4,480 |
Page 2
TOWNSHIP OF CLAY
POVERTY EXEMPTION CALCULATION FORMULA
1. OWNER OF PROPERTY YES_________ NO__________
2. PROPERTY HOMESTEAD SUBMITTED YES_________ NO__________
3. ASSET LEVEL BELOW GUIDELINE YES_________ NO__________
4. INCOME –PER APPLICATION __________________________
5. ASSESSED VALUE __________________________
TAXABLE VALUE __________________________ X
MILLAGE RATE __________________________
ESTIMATED TAXES __________________________
6. FULL EXEMPTION YES_________ NO________
INCOME: $-0- TO STC $ AMOUNT
_________________________________________________________________
_________________________________________________________________
7. PARTIAL EXEMPTION (A/B): Income: _______________________
A: TOP OF STC $ AMOUNT X 3.5%
Establish taxable value so that the % of Income: __________________
Total tax liability is 3.5% of household
Income plus any relief granted by MI compare to est. tax burden:
Homestead Credit (max $1,200)
PARTIAL ASSESSED/TAXABLE SET AT: _______________________________
B: Establish taxable value so that the Income: ________________________
Net tax liability after the Homestead X 5-10%
Credit is within 5-10% of income after credit:
Depending on specifics of the
Application compare to est. tax burden:
PARTIAL ASSESSED/TAXABLE SET AT: ________________________________
8. INCOME DOES NOT MEET POVERTY GUIDELINES
APPLICATION DENIED YES_________ NO__________
SUBSTANTIAL/COMPELLING REASONS: __________________________________
___________________________________________________________________
__________________________________________________________________
-----------------------
F. OTHER REAL ESTATE HOLDINGS
G. ASSET INFORMATION (copies of accounts must be provided)
................
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