CHECKLIST OF REQUIRED POVERTY EXEMPTION INFORMATION YEAR _________________ NAME ______________________________________________________________ ADDRESS ______________________________________________________________ Federal Income Tax form Yes________ No________ State of Michigan Income Tax Form Yes________ No________ Michigan 1040 CR Form Yes________ No________ Household income $_______________ Yes________ No________ Income other persons $_______________ Yes________ No________ Assessed Value ________________ Yes________ No________ Taxable Value ________________ Yes________ No________ Property exceeds 62,500 Assessed Yes________ No________ Savings $_______________ Yes________ No________ Other Real Estate $_______________ Yes________ No________ Has an exemption been granted for more Yes________ No________ than 3 consecutive years? NOTES: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________