Michigan Department of Treasury
4912 (Rev. 01-16)

2016 MICHIGAN Certification of Exemption for Flow-Through Withholding Payments
Issued under authority of Public Act 217 of 2012 and PA 15 of 2013.

Instructions

For purposes of this form, “member” means a Flow-                  Neither  the  member  nor  the  FTE  should  file  this 
Through Entity’s C Corporation or other Flow-Through Entity        certificate with the Michigan Department of Treasury 
member. The term excludes non-resident individuals.                (Treasury).

A member of a Flow-Through Entity (FTE) may elect not to           Both  entities  must  maintain  a  copy  of  this  certificate  in 
be  withheld  upon  under  Michigan  Compiled  Laws  (MCL)         their records in accordance with MCL 206.703(16)(d) and 
206.703(16). The election is accomplished by the member            Rule 205.4103.
filing  this  exemption  certificate,  or  any  comparable 
document containing this information, with the FTE. As             Treasury maintains the right to revoke an exemption 
long  as  an  exemption  certificate  is  received  by  the  FTE   certificate  if  it  finds  that  the  member  or  FTE  is  not 
then it is entirely exempt from the flow-through withholding       abiding  by  the  terms  of  the  certificate  or  the  exemption 
(FTW)  requirements  pertaining  to  that  member  for  the        requirements  as  explained  above.  If  an  exemption 
entire tax year in which the FTE receives the certificate.         certificate is revoked, Treasury will notify the FTE that it 
The FTE is exempt no matter when the FTE receives the              must begin to withhold on the member’s distributive share 
exemption  certificate,  so  long  as  the  FTE  receives  the     of taxable income as required under FTW within 60 days 
exemption certificate within its tax year.                         of that notice. 

PArT 1: MEMbEr INForMATIoN
Taxpayer Name                                                                 Federal Employer Identification Number (FEIN)

Street Address                                                     City                          State ZIP Code

Authorized Contact Person for Tax Matters                          Contact Phone Number Tax Year End Date of Filer (MM-DD-YYYY)

PArT 2: FloW-THrouGH ENTITy INForMATIoN
Taxpayer Name                                                                 FEIN

Street Address                                                     City                          State ZIP Code

Authorized Contact Person for Tax Matters                          Contact Phone Number Tax Year End Date of FTE (MM-DD-YYYY)

PArT 3: CErTIFICATIoN

By signing below, the member certifies:
•  It will file the returns required under Part II (Corporate Income Tax) or Part III (FTW) of the Income Tax Act per MCL 
206.703(16)(a)(i).
•  It will pay or withhold the tax due under Part II (CIT) or Part III (FTW) of the Income Tax Act on the distributive share 
of the business income received from any FTE in which it is a member per MCL 206.703(16)(a)(ii). 
• It will submit to the taxing jurisdiction of Michigan for purposes of collecting the tax due under Part II (CIT) or Part III 
(FTW) of the Income Tax Act and any associated penalty and interest per MCL 206.703(16)(a)(iii). 

Signature of Authorized Contact for the Member                                Date