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Michigan Department of Treasury , STC
L-4175B (Rev. 4/91)
REQUEST for EXEMPTION of PERSONAL PROPERTY STORED in a PUBLIC WAREHOUSE
Issued under authority of MCL Section 211.9(l). Filing is voluntary.
Name of owner, partner or officer completing this form.
Company name
City or township where the stored property is located
I declare, under penalty of perjury, that the person or company named above owns the following personal property;
that this property is located in the city or township named above in a warehouse, dock or port facility; and that it is
not for sale or use in Michigan and will be shipped to out-of-state destinations. I further declare that the
information provided here is true and complete to the best of my knowledge.
Name of Warehouse, Dock
Date
Original
Lot No.
Item
or Port Facility
Stored
Cost
Signature of owner or authorized firm representative named above
Date
Notary Public, State of Michigan
Date my commission expires:
County
Reset Form
Michigan Department of Treasury , STC
L-4175B (Rev. 4/91)
REQUEST for EXEMPTION of PERSONAL PROPERTY STORED in a PUBLIC WAREHOUSE
Issued under authority of MCL Section 211.9(l). Filing is voluntary.
Name of owner, partner or officer completing this form.
Company name
City or township where the stored property is located
I declare, under penalty of perjury, that the person or company named above owns the following personal property;
that this property is located in the city or township named above in a warehouse, dock or port facility; and that it is
not for sale or use in Michigan and will be shipped to out-of-state destinations. I further declare that the
information provided here is true and complete to the best of my knowledge.
Name of Warehouse, Dock
Date
Original
Lot No.
Item
or Port Facility
Stored
Cost
Signature of owner or authorized firm representative named above
Date
Notary Public, State of Michigan
Date my commission expires:
County