Hardship
Exemption Application
REASON FOR EXEMPTION REQUEST
page 3
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.
NOTICE: A copy of your latest Federal income tax return, State income tax return, (MI1040); and your Homestead Property Tax Credit claim ( MI1040CR 1,2,3, or 4) MUST be attached as proof on income.
NOTICE: Do not sign until witnessed by the Supervisor, Assessor, Board of Review or Notary Public.
STATE OF
The undersigned, being duly sworn, deposed and says that the statements made in the foregoing application are true and that he/she has no money, income or property other than mentioned herein.
Petitioner
Subscribed and sworn this _______________day of ________________________200___
Signature
Assessor 
Supervisor BOR Member Notary Public
This application shall be filed after January 1, but before the day
prior to the last day of Board of Review.
Please submit to
____________________________________________________________________________________________________________
FOR BOARD OF REVIEW USE
Disposition by Board of Review Date _________________________________
Denied ____________________ Approved ____________________________
Current Assessment: _______________Current Taxable Value _______________________
Revised Assessment _______________Revised Taxable Value ______________________
BOR Chairperson _____________________________________________
BOR Member _________________________________________________
BOR Member _________________________________________________