Principal Residence

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Michigan Department of Treasury 2368 (Rev. 03-16)

ASSESSOR’S DATE STAMP

PULQFLSDO RHVLGHQFH E[HPSWLRQ PRE AI¿GDYLW Issued under authority of Public Act 206 of 1893.

5HDGWKHLQVWUXFWLRQVEHIRUHFRPSOHWLQJWKHIRUP7KLVIRUPLVQRWYDOLGXQOHVVFHUWL¿HGE\WKHDVVHVVRU Do not submit this form if the property is not your principal residence and/or any of the disqualifying factors apply as listed in MCL 211.7(cc). Type or print in blue or black ink.

PART 1: PROPERTY INFORMATION 7\SHRUSULQWOHJLEO\8VHDVHSDUDWHIRUPIRUHDFKSURSHUW\WD[LGHQWL¿FDWLRQQXPEHU 3URSHUW\7D[,GHQWL¿FDWLRQ1XPEHU

1DPHRI/RFDO8QLW&KHFN7RZQVKLSRU&LW\ 3. County 7RZQVKLS City

4. Street Address of Property (Provide a Complete Address) 1DPHRI2ZQHU)LUVW0LGGOH/DVW

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XXX-XX'DWH\RXRZQHGDQGRFFXSLHGWKHSURSHUW\LQOLQH ............................................................................................... 11. The property in line 1 above is my:

11a. 11b.

Month Day Principal residence 8QRFFXSLHGDGMRLQLQJRUFRQWLJXRXVSURSHUW\WKDWLVFODVVL¿HGUHVLGHQWLDORUWLPEHUFXWRYHU

12. /LVWWKHSHUFHQWDJHWR RIWKHSURSHUW\WKDWLVRFFXSLHGE\WKHRZQHUFODLPLQJWKHSURSHUW\DVDSULQFLSDO UHVLGHQFH,IWKHSURSHUW\KDVPRUHWKDQRQHKRPHRQLWLWLVDPXOWLGZHOOLQJXVHGIRUSXUSRVHVRWKHUWKDQD SULQFLSDOUHVLGHQFHRUSDUWLDOO\UHQWHGWKHRZQHUPD\FODLPRQO\DSDUWLDOH[HPSWLRQ3OHDVHFRQVXOWZLWK\RXU ORFDODVVHVVRUWRGHWHUPLQHWKHSHUFHQWDJHRIWKHH[HPSWLRQWKHRZQHULVDOORZHGWRFODLPLQWKHVHVLWXDWLRQV ...... 12.

% Yes

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Yes

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Yes

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Yes

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13. Have you claimed a principal residence exemption for another Michigan principal residence? ............................... 13.

Year

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PART 2: CERTIFICATION &HUWL¿FDWLRQ I certify under penalty of perjury the information contained on this document is true and correct to the best of my knowledge. 20. 2ZQHU¶V6LJQDWXUH

Date

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Date

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LOCAL GOVERNMENT USE ONLYGRQRWZULWHEHORZWKLVOLQH 23. ,QGLFDWHSURSHUW\FODVVL¿FDWLRQ ................................................................................................................................ 'LGWKH$VVHVVRU$SSURYHRU'HQ\WKH$I¿GDYLW"

Approved

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Denied (Attach a copy of the Local Unit Denial)

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