Form 1428 - Application For State Treasurer'S Approval To Issue Long-Term Securities
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5Michigan Department of Treasury
This form is issued under the authority of P.A.
1428 (Rev. 2-02)
34 of 2001. If your municipality does not have
Application for State Treasurer's Approval
qualified status, you must file this form to apply
for approval of the State Treasurer before
to Issue Long-Term Securities
Long-term Municipal Securities can be issued.
INSTRUCTIONS: Complete all parts of this application. The Department of Treasury may request additional information.
FILE WITH: Local Audit & Finance Division, Michigan Department of Treasury, P.O. Box 30728, Lansing, MI 48909-8228.
Direct questions to (517) 373-0660 or e-mail to Treas_MunicipalFinance@michigan.gov.
The municipality identified below applies for permission to issue securities under authority of the statute(s) and
resolution as follows:
Date Resolution Was Adopted
P.A. 34 of 2001, as amended
P.A.
Legal Name of Municipality
Legal Classification
County (ies)
Title of Security
Amount of Security
Date of Security
Chief Administrative Officer - Person
Address and Telephone No.
Bond Counsel - Person and Firm
Address and Telephone No.
Local Attorney - Person and Firm
Address and Telephone No.
Financial Consultant - Person and Firm
Address and Telephone No.
Underwriter - Person and Firm
Address and Telephone No.
Engineer or Architect - Person and Firm
Address and Telephone No.
CERTIFICATION: I, the undersigned, certify that this application and the attachments were authorized by the governing body of this
municipality, and that they are complete and accurate in all respects. I further certify that the funds on hand (if any) listed on page 4 of
this application are on hand and available for use on this project.
Chief Administrative Officer Name and Title (Typed or Printed)
Chief Administrative Officer's Signature
Date
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