Form 3694 - Request For Certificate Of Completion For Brownfield Redevelopment Credit Project Form
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5Michigan Department of Treasury
Enter the Assigned Project Number
3694 (Rev. 9-01)
Request for Certificate of Completion for
Enter the Date the Project was Completed
Brownfield Redevelopment Credit Project
PART 1 QUALIFIED TAXPAYER INFORMATION (As identified on the Preapproval Letter received)
2. Federal Employer ID No (FEIN) or Treasury (TR) No.
1. Qualified Taxpayer Name
3. Total Actual Eligible Investment For the Project
d/b/a
$
Address (Street, P.O. Box, RR#)
4. Did you own or lease the eligible property at the time
the eligible investment was made?
Yes
No
If Yes, check the one that applies.
Own
Lease
City, State, ZIP
If No, you are not a qualified taxpayer and are not
eligible for this credit.
5.
Has the Department of Environmental Quality ever sued or issued a unilateral order to you pursuant to Part 201
of the Natural Resources and Environmental Protection Act, P.A. 451 of 1994, MCL 324.20101 to 324.20142, to
compel response activity on or to the eligible property, or expended any state funds for response activity on or to
the eligible property and demanded reimbursement for those expenditures from you?
Yes
No
If yes, you are not a qualified taxpayer and are not eligible for this credit.
1.
Qualified Taxpayer Name
2. Federal Employer ID No (FEIN) or Treasury (TR) No.
d/b/a
3. Total Actual Eligible Investment For the Project
$
Address (Street, P.O. Box, RR#)
4. Did you own or lease the eligible property at the time
the eligible investment was made?
Yes
No
If Yes, check the one that applies.
Own
Lease
City, State, ZIP
If No, you are not a qualified taxpayer and are not
eligible for this credit.
5.
Has the Department of Environmental Quality ever sued or issued a unilateral order to you pursuant to Part 201
of the Natural Resources and Environmental Protection Act, P.A. 451 of 1994, MCL 324.20101 to 324.20142, to
compel response activity on or to the eligible property, or expended any state funds for response activity on or to
the eligible property and demanded reimbursement for those expenditures from you?
Yes
No
If yes, you are not a qualified taxpayer and are not eligible for this credit.
1.
Qualified Taxpayer Name
2. Federal Employer ID No (FEIN) or Treasury (TR) No.
d/b/a
3. Total Actual Eligible Investment For the Project
$
Address (Street, P.O. Box, RR#)
4. Did you own or lease the eligible property at the time
the eligible investment was made?
Yes
No
If Yes, check the one that applies.
Own
Lease
City, State, ZIP
If No, you are not a qualified taxpayer and are not
eligible for this credit.
5.
Has the Department of Environmental Quality ever sued or issued a unilateral order to you pursuant to Part 201
of the Natural Resources and Environmental Protection Act, P.A. 451 of 1994, MCL 324.20101 to 324.20142, to
compel response activity on or to the eligible property, or expended any state funds for response activity on or to
the eligible property and demanded reimbursement for those expenditures from you?
Yes
No
If yes, you are not a qualified taxpayer and are not eligible for this credit.
Continued on Page 2.
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