PDF document
- 1 -
                                                                                                                              Reset Form

Michigan Department of Treasury                                                                                               TE-SOURCE
3828 (Rev. 05-13)
Application for Air Pollution Control Tax Exemption Certificate
Issued under authority of P.A. 451 of 1994, as amended, Part 59. Filing is mandatory.
General Information. Complete All Boxes.
                                                                                                                           
   New               Amend                  Transfer Certificate #1
PART 1   SOURCE IDENTIFICATION.  This section pertains to the facility where the air pollution control equipment is located. 
1. Company Name (Applicant must be owner of facility)                                                2. AQD Source ID (SRN)

Address (equipment location)                                                                         3. Primary SIC Code

   City, State, ZIP Code                                                                           4. County

 5. Name of Taxing Authority.  Select one only.         City of
                                                          Township of
                                                          Village of
 6. Describe the major process or processes of the pollution control equipment at the facility.

  7. Enter the total value of requested tax exemption.  Indicate whether value is "Estimated" or "Final" by checking the appropriate box.  
      (If cost is estimated, you must supply the final cost within 90 days of completion of construction.) May apply with estimated costs only if project is 
      not completed.                                           Estimated               Final
   $

 PART 2: TECHNICAL CONTACT/PREPARER.  Technical contact should be able to respond to technical questions 
 concerning this application.  Enter Preparer information, if different than Technical Contact.
  8. Technical Contact Name                                                           Position/Title

      E-mail Address                                                                  Telephone Number              Fax Number

  9. Preparer Name                                                                    Position/Title

      Company Name                                                                    Telephone Number              Fax Number

      Company Mailing Address                                                         E-Mail Address

 PART 3:  COMPANY REPRESENTATIVE.  COMPANY REPRESENTATIVE INFORMATION.  Name and address for Tax Exemption ResponseName and address for Tax Exemption response. Complete all boxes.
 10. Company Official Name                                                           Position/Title

 Street Address                                                                     City, State, ZIP Code

      E-mail Address                         Telephone Number                                               Fax Number

I certify that all the information contained in this tax exemption application is true and correct to the best of my knowledge.
     Signature of Company Official (No authorized agents)                                                           Date

  FOR OFFICE USE ONLYFOR STATE USE ONLY
 Application Number                    Reviewed By                                   Date Received/Date Reviewed  LUCI Code



- 2 -
3828, Page 2                                                                                                      TE-EQUIPMENT

Application for Air Pollution Control Tax Exemption Certificate
Air Pollution Control Equipment Description. May attach multiple TE-Equipment pages to one TE-Source.
 PART 4:  GENERAL INFORMATION
13. AQD Source ID (SRN)                                                          14. Emission Unit

15. Describe the air pollution control equipment, the operational procedure, how it will minimize or control air pollution, and any function the equipment 
serves that is other than for ambient air pollution control.  Include non-air pollution control uses.

16. Permit Number/Permit Exemption Rule (must  17. Beginning Date of Construction                    18. Projected/Completion Date of Construction
be provided)

 PART 5:  EQUIPMENT AND COST DETAILS.  For the equipment associated with the air pollution control that is claimed to be 
 exempt, provide a description, total cost, and the portion of the total cost being claimed as exempt for each of the items listed.  If an 
 item does not exist, indicate "N/A." Provide plans and specifications for the facility, as an additional attachment, per Section 5902 
 (1). Provide an itemized list of equipment totaling the amount requested in box #7. 
19. Describe the air pollution control equipment (attach additional pages if necessary.    Total Cost of 19 
Costs must be separated into appropriate categories in 20-24).                             $
                                                                                           Portion Claiming Tax Exempt (provide itemized list)
                                                                                           $
                                                                                                                  
20. Describe the stack and specify other process/processes equipment associated with       Total Cost of 20
this stack.                                                                                $
                                                                                           Portion Claiming Tax Exempt (provide itemized list)
                                                                                           $
21. Describe the ancillary equipment (foundations, enclosures, electrical equipment, etc.). Total Cost of 21      
                                                                                           $
                                                                                           Portion Claiming Tax Exempt (provide itemized list)
                                                                                           $
22. Describe the fans and motors.  Distinguish between static pressure needed for the      Total Cost of 22 
plant's HVAC and process applications, and that needed for air pollution control 
equipment.                                                                                 $
                                                                                           Portion Claiming Tax Exempt (provide itemized list)
                                                                                           $
23. Describe the ductwork and hoods including the percentage of ductwork necessary for  Total Cost of 23
air pollution control purposes. (Do not include the percentage which is for the benefit of 
personnel).                                                                                $
                                                                                           Portion Claiming Tax Exempt (provide itemized list)
                                                                                           $
24. Describe miscellaneous costs (engineering costs, administrative fees, feasibility study  Total Cost of 24
costs, etc.).
                                                                                           $
                                                                                           Portion Claiming Tax Exempt (provide itemized list)
                                                                                           $

 25. Value of recovered product (must provide per Sec. 5902(2))                           Total of 19-24 
$                                                                                                        $
26. Is equipment replacing an existing piece of equipment already exempt?                                    Yes  No
                                                                               If Yes, enter the Tax Exemption Certificate number ____________________________________



- 3 -
3828, Page 3                                                                                                             TE-PROCESS

Application for Air Pollution Control Tax Exemption Certificate
Process Change Description - Complete only if changing a current process to a new improved process
PART 6:  ORIGINAL PROCESS AND ALTERNATIVE (THEORETICAL) CONVENTIONAL CONTROL
 27. AQD Source ID (SRN)                                                       28. Emission Unit

 29. Describe the original process and the operational procedure of this emission unit, with specific attention paid to the portion(s) of the process being 
changed. (A detailed narrative is critical.)

 30. Describe or list the air pollution control devices employed by the original process.

 31. Describe the type and magnitude of pollutants associated with this emission unit.                               32. Permit Number/ Permit 
                                                                                                                     Exemption Rule (must provide 
                                                                                                                     one)

33. Describe a control device that could have been employed to reduce emissions to the same extent as the process    33a. Estimated cost of 
change.  Give details concerning whether or not it could (physically) have been done, and whether or not it would be theoretical/conventional control
as effective as the process change at controlling pollution. (See Example 1 in instructions). (33 and 33a must be 
completed)
                                                                                                                     $

 PART 7:  NEW PROCESS - The shaded area in items 43 and 44 are for Office Use Only.
34. Describe the process and the operational procedure of this emission unit, with specific attention being paid to the portion(s) of the process that       
were/are being changed. Provide plans, specifications and drawings showing position of equipment relative to outer shell of building.

35. Describe the air pollution control devices employed by the new process.  IMPORTANT:  A TE-EQUIPMENT form should be submitted for  
equipment that is solely used for air pollution control.

36. Describe the type and magnitude of pollutants associated with this new emission unit.  

37. Emission Unit                           38. Permit Number/ Permit          39. Beginning Date of    40. Projected/Actual Completion
                                             Exemption Rule (if different from Construction              
                                            item 28)

41. Total Cost of Process Change            42. Portion Claiming Tax Exempt    43. Exemption Factor     44. Exemption Value
$                                           $                                        25% or __________% $
45. Gross Value of Recovered Product
$



- 4 -
3828, Page 4

                           Instructions for Completing Form 3828,
                Application for Air Pollution Control Tax Exemption Certificate

GENERAL INSTRUCTIONS                                                       Part 1: Source Identification
One TE-SOURCE is required for each submittal; and one or both              This section pertains to the facility where the air pollution control 
TE-EQUIPMENT or TE-PROCESS is also required. Complete                      equipment is located.
the number of forms appropriate for your situation. Multiple               Line 2: AQD Source ID (SRN). Enter the state registration number 
TE-Equipment and TE-Process forms may be filed under one                   for your facility issued by the DEQ.
TE-Source [IMPORTANT: Forms must be fully completed. 
                                                                           Line 3: Primary SIC Code. Enter the Standard Industrial 
An incomplete application will be returned to the preparer 
                                                                           Classification (SIC) code that best describes the major product or 
unprocessed.]
                                                                           service produced. This code must be a four digit numeric code not 
For full consideration in the year in which the material is                ending in zero based upon the Standard Industrial Classification 
submitted, a complete application must be received by June 15.             Manual (1987), or a six-digit code based upon the North American 
Mail THREE COPIES (no binders) of the completed forms and                  Industry Classification System (1997).
supplemental information (written narrative, list of equipment 
                                                                           Part 2: Technical Contact/Preparer Information
with individual costs, one set of plans) to:
                                                                           Enter the information in #8 of the person who can respond to 
     Michigan Department of Treasury
                                                                           technical questions about the application. If the Preparer is different 
     State Tax Commission
                                                                           than Technical Contact Person, enter the Preparer information in 
     P.O. Box 30471
                                                                           #9.
     Lansing, MI 48909-7971
     Telephone: 517-335-7491                                               Part 3: Company Official
                                                                           The Company Official is required to be an employee of the 
For guaranteed receipt by the State Tax Commission, it is                  company that is seeking the tax exemption. The application 
recommended that applications and attachments are sent by                  response will be sent to the Company Official. By signing and 
certified mail.                                                            dating  this  application,  the  Company  Official  authorizes  the 
                                                                           Michigan Department of Treasury and the DEQ to discuss this 
Refer to the following Department of Environmental Quality 
                                                                           project with the technical contact person named in Part 2.
(DEQ) Web site documents for assistance in completing an air 
pollution control tax exemption application:                               TE-EQUIPMENT
                                                                           The TE-EQUIPMENT provides information about air pollution 
DEQ Air Quality Web site
                                                                           control equipment that may be eligible for tax exemption. If a tax 
www.michigan.gov/deq/0,1607,7-135,3310---,00.html                          exemption is being sought for equipment from multiple emission 
DEQ Air Pollution Guidance Document                                        units, complete a separate form for each emission unit. A separate 
w w w. d e q . s t a t e . m i . u s / d o c u m e n t s / D E Q - A Q D - page should be attached for each additional explanation. Each page 
                                                                           must be identified as TE-Equipment or TE-Process along with the 
Tax_exemption_application_guidance_document.pdf
                                                                           corresponding Emission Unit name from box 14. Applications with 
DEQ Permit Guide Book                                                      more than one explanation per page will not be accepted. Items 19
www.deq.state.mi.us/documents/deq-ess-                                     thru 24 may require additional space for explanation.
permitspermitguidebook.pdf
                                                                           Part 4: General Information
DEQ Operational Memorandum #6 – Emissions Units                            Line 13: AQD Source ID (SRN). Enter the state registration 
www.deq.state.mi.us/documents/deq-aqd-opmemo6.pdf                          number for your facility issued by the DEQ.
DEQ Environmental Permits,Licenses & Certifications                        Line 14: Emission Unit. If the equipment is part of a Renewable 
http://www.michigan.gov/deq/1,1607,7-135-6132_6830---,00.                  Operating Permit, Permit to Install, or is reported in the Michigan 
html                                                                       Air Emission Reporting System (MAERS), it may have an 
                                                                           emission unit associated with it. If so, enter thename of the 
LINE-BY-LINE INSTRUCTIONS                                                  emission unit to which it belongs. If not, the Michigan Department 
Lines not listed are explained on the form. Complete all boxes or          of Environmental Quality, Air Quality Division (DEQ/AQD), 
indicate N/A.                                                              “Operational Memorandum No. 6” will assist you in defining 
TE-SOURCE                                                                  one for your facility. A separate TE-EQUIPMENT should be 
                                                                           submitted for each emission unit. Multiple TE-Process and TE-
The TE-SOURCE provides general information about the facility 
                                                                           Equipment forms may be filed under one TE-Source.
including contact person and preparer identification. Complete a 
TE-SOURCE for each submittal. If additional space is required              Line 16: Permit Number/Exemption Rule. Enter the permit number 
to complete an answer, attach additional pages.                            or permit exemption rule that covers the process equipment. One 
                                                                           must be provided.



- 5 -
3828, Page 5

Part 5: Equipment and Cost Details                                  Line 41: Total Cost of Process Change. Enter the total cost of 
Provide a description of the equipment associated with the air      the process change, not including costs of air pollution control 
pollution control that is claimed to be exempt. Provide one set     devices listed in TE-EQUIPMENT.
of plans and provide an itemized list of equipment and costs.       Line 42: Portion Claiming Tax Exempt. A standard 25% of costs 
Consider incremental costs when providing the value to be           associated with process changes is tax exempt. Enter the portion 
considered for tax exemption. If a building is constructed solely   of the total cost for which you are claiming a tax exemption. (See 
for the purpose of protecting an air pollution control device, the  example 2)
entire cost of the building may be tax exempt. If, however, the     Line 45: Value of Recovered Product. Enter the gross commercial 
size of the building is increased to allow for additional warehouse or productive value derived from any materials captured or 
space, the entire cost of the building would not be tax exempt.     recovered by the air pollution control equipment, calculated 
(See Example 1)                                                     on a yearly basis. Include any financial benefit from increased 
Line 25: Value of Recovered Product. Enter the gross commercial     production capabilities as a result of a change in the process. This 
or productive value derived from any materials captured or          is required per Sec. 5902(2).
recovered by the air pollution control equipment calculated on a 
yearly basis. This is required per Sec. 5902(2).
TE-PROCESS
The TE-PROCESS provides detailed cost information about a 
                                                                    Example 1
process change that has contributed to an improvement in air 
                                                                    A building is constructed to protect an air 
emission. A tax exemption of up to 25% is awarded for eligible 
                                                                    pollutioncontrol device and serve as a warehouse. 
equipment. If a tax exemption is being sought for equipment 
                                                                    To calculate the tax exempt portion, the applicant 
from multiple emission units, complete a separate form for 
                                                                    must determine the total cost of the building, less 
each emission unit. If additional space is required to complete 
                                                                    the cost of the portion of the building serving as a 
an answer, attach additional pages. A separate page should 
                                                                    warehouse.
be attached for each additional explanation. Each page must 
be identified as TE-Equipment or TE-Process along with the          Total Cost of Building                      $100,000 
corresponding Emission Unit name from box 14. Applications          Less Cost of Warehouse Portion              (80,000)
with more than one explanation per page will not be accepted.       Tax Exempt Portion                  $20,000.
Items 29 thru 36 may require additional space for explanation.
Part 6: Original Process and Alternative
(Theoretical) Conventional Control
Line 27: AQD Source ID (SRN). Enter the state registration          Example 1
number for your facility issued by the DEQ.                         Case 1: A $200,000 process change to a coating line
Line 28: Emission Unit. If the equipment is part of a Renewable     results in lower VOC emission. Theoretically, a 
Operating Permit, Permit to Install, or is reported in the          thermal oxidizer and capture equipment could have 
Michigan Air Emission Reporting System (MAERS), it may              had the same net decrease in emission, but would’ve 
have an emission unit associated with it. If so, enter the name     cost $100,000. In this case, a 25% tax exemption for 
of the emission unit to which it belongs. If not, the Michigan      the process change would be appropriate, thereby 
Department of Environmental Quality, Air Quality Division,          making $50,000 eligible for tax exemption.
“Operational Memorandum No. 6” will assist you in defining an       Case 2: A $500,000 process change to a coating line
emission unit for your facility. A separate TE-PROCESS should       results in lower VOC emission. Theoretically, a 
be submitted for each emission unit. Multiple TE-Process and        thermal oxidizer and capture equipment could have 
TE-Equipment forms may be filed under one application.              had the same net decrease in emission, but would’ve 
                                                                    cost $100,000. In this case, the $100,000 control 
Part 7: New Process
                                                                    equipment addition would’ve had the same net 
Line 37: Emission Unit. If the new equipment is part of a           effect, and is less than 25% of $500,000 ($125,000). 
Renewable Operating Permit, Permit to Install, or is reported in    Therefore, in this case, a tax exemption of $100,000 
the Michigan Air Emission Reporting System (MAERS), it may          would be issued, even though the $500,000 process 
have an emission unit associated with it. If so, enter the name of  change was the actual action taken.
the emission unit to which it belongs. It is possible that it will 
have the same name as that listed on line 28. 






PDF file checksum: 3157821842

(Plugin #1/8.13/12.0)