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Michigan Department of Treasury
891 (Rev. 12-20)

Application for Water Pollution Control Tax Exemption Certificate
Issued under authority of Public Act 451 of 1994, as amended, Part 37.  Filing is mandatory.

General Information. Complete All Boxes.
New                       Amended                     Transfer Certificate #2

PART 1: SOURCE INDENTIFICATION (This section pertains to the facility where the water pollution control equipment is located).
1. Company Name (applicant must be owner of facility)                         2. County

3. Address (equipment location)                                               4. City, State, ZIP Code

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 file under 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 (Name and address for Tax Exemption response. Complete all boxes).
10. Company Official Name                                                     Position/Title

Street Address                                                                City, State, ZIP Code

E-mail                                                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 ONLY
Application Number              Reviewed By                                   Date Recieved/Date Reviewed       LUCI Code

891, Page 2
                                                                                                                                   TE-EQUIPMENT

Application for Water Pollution Control Tax Exemption Certificate
Water Pollution Control Equipment Description

PART 4: GENERAL INFORMATION
11. Describe the water pollution control equipment, the operational procedure, how it will minimize or control water pollution, and any function the equipment 
serves. Include non-water pollution control uses.

12. Beginning Date of Construction                                                    13. Projected/Completion Date of Construction

PART 5: EQUIPMENT AND COST DETAILS (For the equipment associated with the water 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 of the facility as an additional attachment per Section 3702(1). Provide an itemized list of equipment totaling the 
amount requested in box #7).
14. Describe the water pollution control equipment. (attach additional pages if necessary.  Costs must be Total Cost of 14
separated into appropriate categories in sections 14 thru 16).

                                                                                                          Portion Claiming Tax Exempt (Provide itemized list)

15. Describe the ancillary equipment (foundations, enclosures, electrical equipment,                      Total Cost of 15
wastewater storage, chemical treatment storage tanks, pumps, piping, instrumentation &
sludge dewatering equipment, etc.)
                                                                                                          Portion Claiming Tax Exempt (Provide itemized list)

16. Describe miscellaneous costs (engineering, administrative fees, etc.)                                 Total Cost of 16

                                                                                                          Portion Claiming Tax Exempt (Provide itemized list)

17. Value of recovered product (must provide per Sec. 3702(2))
$                                                                                                         Total of 14-16

891, Page 3

                 Instructions for Completeing Form 891, Application for 
                        Water Pollution Control Tax Exemption Certificate

GENERAL INSTRUCTIONS                                                   Part 5: Equipment and Cost Details
One TE-SOURCE is required for each submittal; and one TE-              Provide a description of the equipment associated with the water 
EQUIPMENT is also required.  [IMPORTANT: Forms must be                 pollution control that is claimed to be exempt.
fully completed. An incomplete application will be returned 
to the preparer unprocessed.]                                          Consider incremental costs when providing the value to be 
                                                                       considered for tax exemption. If a building is constructed solely 
For full consideration in the year in which the material is submitted, for the purpose of protecting a water pollution control device, the 
a complete application must be received by June 15. For faster         entire cost of the building may be tax exempt. If, however, the 
service, email the completed forms and supplemental                    size of the building is increased to allow for additional warehouse 
information (written narrative, list of equipment with                 space, the entire cost of the building would not be tax exempt. 
individual costs, one set of plans) to PTE@michigan.gov.               (See Example 1.)
An additional submission option is to mail the completed forms 
and supplemental information (written narrative, list of equipment     Line 16. Value of Recovered Product.           Enter the gross 
with individual costs, one set of plans) to Michigan Department        commercial or productive value derived from any materials 
of Treasury, State Tax Commission, PO Box 30471, Lansing, MI           captured or recovered by the water pollution control equipment 
48909.                                                                 calculated on a yearly basis. This is required per Sec. 3702(2).

LINE-BY-LINE INSTRUCTIONS                                              Example 1
Lines not listed are explained on the form. Complete all boxes or      A building is constructed to protect a water pollution control device 
indicate N/A.                                                          and serve as a warehouse.  To calculate the tax exempt portion, 
                                                                       the applicant must determine the total cost of the building, less 
TE-SOURCE                                                              the cost of the portion of the building serving as a warehouse.
The TE-SOURCE provides general information about the facility 
including contact person and preparer identification. Complete a       Total Cost of Building             $100,000
TE-SOURCE for each submittal. If additional space is required to 
complete an answer, attach additional pages.                           Less Cost of Warehouse Portion       (80,000)

Part 1: Source Identification                                          Tax Exempt Portion                   $20,000
This section pertains to the facility where the water pollution 
control equipment is located.

Part 2: Technical Contact/Preparer Information
Enter the information in number 8 of the person who can respond 
to technical questions about the application. If the Preparer is 
different  than  Technical  Contact  Person,  enter  the  Preparer 
information in number 9.

Part 3: Company Official
The Company Official is required to be an employee of the 
company that is seeking the tax exemption. The application 
response will be sent to the Company Official. By signing and 
dating  this  application,  the  Company  Official  authorizes  the 
Michigan Department of Treasury and the Michigan Department 
of Environmental Quality to discuss this project with the technical 
contact person named in Part 2.
 
TE-EQUIPMENT
The TE-EQUIPMENT provides information about water pollution 
control equipment that may be eligible for tax exemptions. A 
separate page should be attached for each additional explanation. 

Each page must be identified as TE- Equipment. Items 11, 14, 15 
and 16 may require additional space for explanation.