Form 4567 - Michigan Business Tax Annual Return

4567, Page 3

FEIN or TR Number

PART 3: TOTAL MICHIGAN BUSINESS TAX

51. Total Michigan Business Tax Before Surcharge and Credits. Add lines 27 and 50 ...................................

51.

52. Annual Surcharge. Enter the lesser of $6,000,000 or line 51 multiplied by 21.99% (0.2199) ...........................

52.

53. Tax Liability After Surcharge. Add lines 51 and 52 ............................................................................................

53.

54. Nonrefundable credits from Form 4568, line 40 ................................................................................................

54.

55. Total Tax After Nonrefundable Credits. Subtract line 54 from line 53. If less than zero, enter zero .............

55.

56. Recapture of Certain Business Tax Credits and Deductions from Form 4587, line 13 ......................................

56.

57. Total MBT Tax Liability. Add lines 55 and 56...................................................................................................

57.

58. Corporate Income Tax adjustment from Form 4946, line 39 .............................................................................

58.

59. Total Tax Liability. Add lines 57 and 58 ...........................................................................................................

59.

PART 4: PAYMENTS, REFUNDABLE CREDITS AND TAX DUE

60. Overpayment credited from prior MBT return ....................................................................................................

60.

61. Estimated tax payments ....................................................................................................................................

61.

62. Flow-Through Withholding payments ................................................................................................................

62.

63. Tax paid with request for extension ...................................................................................................................

63.

64. Refundable credits from Form 4574, line 23 .....................................................................................................

64.

65. Payment and credit total. Add lines 60 through 64. (If not amending, then skip to line 67.) .............................

65.

a. Payment made with the original return ......................

66a.

AMENDED

b. Overpayment received on the original return ............

66b.

66.

RETURN

ONLY

c. Add lines 65 and 66a and subtract line 66b

from the sum.............................................................. ........................................................

66c.

67. TAX DUE. Subtract line 65 (or line 66c, if amending) from line 59. If less than zero, leave blank ....................

67.

68. Underpaid estimate penalty and interest from Form 4582, line 38 ....................................................................

68.

% =

69. Annual return penalty (a)

(b)

plus interest (c)

. Total ...... 69d.

70. PAYMENT DUE. If line 67 is blank, go to line 71. Otherwise, add lines 67, 68 and 69d ..................................

70.

PART 5: REFUND OR CREDIT FORWARD

71. Overpayment. Subtract lines 59, 68 and 69d from line 65 (or line 66c, if amending) .

If less th an zero, leave blank (see instructions) .................................................................................................

71.

72. CREDIT FORWARD. Amount on line 71 to be credited forward and used as an estimate for next tax year ....

72.

73. REFUND. Amount on line 71 to be refunded.....................................................................................................

73.

Taxpayer Certification.

Preparer Certification.

I declare under penalty of perjury that the information in this

I declare under penalty of perjury that this

return and attachments is true and complete to the best of my knowledge.

return is based on all information of which I have any knowledge.

Preparer’s PTIN, FEIN or SSN

By checking this box, I authorize Treasury to discuss my return with my preparer.

Authorized Signature for Tax Matters

Preparer’s Business Name (print or type)

Authorized Signer’s Name (print or type)

Date

Preparer’s Business Address and Telephone Number (print or type)

Title

Telephone Number

Return is due April 30 or on or before the last day of the 4th month after the close of the tax year.

WITHOUT PAYMENT. Mail return to:

WITH PAYMENT. Pay amount on line 70. Mail check and return to:

Michigan Department of Treasury, PO Box 30783, Lansing MI 48909

Michigan Department of Treasury, PO Box 30113, Lansing MI 48909

Make check payable to “State of Michigan.” Print taxpayer’s FEIN or TR

Number, the tax year, and “MBT” on the front of the check. Do not staple the

check to the return.

0000 2012 11 03 27 8

Form 4567 - Michigan Business Tax Annual Return - 2012 Page 3

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