Form 4095 - Request And Consent For Disclosure Of Tax Return And Tax Return Information
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Michigan Department of Treasury
4095 (Rev. 2-08)
Request and Consent for Disclosure of Tax Return and Tax Return Information
Issued under authority of Public Act 122 of 1941, MCL 205.1.
The Revenue Act, Public Act 122 of 1941, MCL 205.28(1)(f), makes all information acquired in administering taxes confidential. The Michigan
Department of Treasury collects a fee for copies of tax returns or tax return information requested by local units of government or other third parties.
Taxpayers may receive copies of their personal tax returns at no charge. The current fee schedule is listed below (see Part 3).
Part 1: Taxpayer Information
Enter the name of the individual or business, address and account number for which the tax information is being requested.
Taxpayer Last Name
First Name
MI
Social Security Number or FEIN
Telephone Number
(
)
Secondary Taxpayer Last Name
First Name
MI
Social Security Number or FEIN
Telephone Number
(
)
Address (Street)
City
State
ZIP Code
Tax Type
Income Tax
Single Business Tax
Sales, Use and Withholding
___________________________________________
Tax Year(s)
Tax Forms
Part 2: Authorization
I authorize the State of Michigan, Department of Treasury to furnish tax returns and/or tax return information specified in Part 1 to the
appointee listed below. This authorization expires in six months and is not a substitute for a formal Power of Attorney, Form
151.
Appointee Name
E-mail Address
Telephone Number
(
)
Address (Street)
City
State
ZIP Code
Taxpayer's Signature
Date
Taxpayer's Signature
Date
Part 3: Fee Schedule
Local units of government or other third parties must pay the fee described here. Taxpayers may receive copies of their personal
tax returns at no charge. Payment for tax return information must accompany the request. Make checks payable to the State of
Michigan and write index code #24152 on the check.
First Year
$ 5.00
$ 5.00
Additional Year(s)
$ 3.00 x ______
Fee Total
Submit your request with payment to the following address:
For Express Deliveries, use:
Technical Services Division, Disclosure Unit
Technical Services Division, Disclosure Unit
Michigan Department of Treasury
Michigan Department of Treasury
P.O. Box 30698
430 W. Allegan Street
Lansing, MI 48909
Lansing, MI 48922
Please allow 60 days for processing your request.
Telephone: (517) 636-4239
E-mail:
Treas_Disclosure@michigan.gov
Treasury Use Only (to be completed by Disclosure Officer)
1.
The attached information is furnished for tax year(s) __________________________________________________________ .
2.
No record of filing a return for tax year(s) ___________________________________________________________________ .
3.
No tax record exists for the previous five years under the account number provided.
4.
The account number submitted needs to be verified for accuracy.
5.
The account number provided is being used by another taxpayer.
6.
Other _______________________________________________________________________________________________
____________________________________________________________________________________________________ .
Fee Received
Fee Paid in Full
Fee Due
Disclosure Officer Approval
Date Completed
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