Form 3277 - Michigan Claim For Refund Of Unclaimed Property - 2002

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Treasury Use Only
Michigan Department of Treasury
Claim ID
3277 (Rev. 9-02)
Date
Michigan Claim for Refund of Unclaimed Property
User ID
Issued under Public Act 29 of 1995. Filing is required to obtain a refund.
To request your refund, complete the claimant information below, verify the owner information and attach the required documentation.
Sign this claim in the presence of a notary public. There is no charge for this service.
A. Claimant Information
Claimant's Social Security No. or FEIN
Daytime Phone No.
What is your relationship to the property owner?
Self
Parent
Guardian
Trustee
Heir
Executor/Administrator
Other, specify __________________________
B. Owner Information
Owner's Name
Owner's Social Security No. or FEIN
Co-Owner's Name
Co-Owner's Social Security No or FEIN
C. Holder Information
Name of Financial Institution
Holder's FEIN
Location (City, State, ZIP Code)
Date Property Was Originally Reported
If the property was reported before 1988, include the
Escheat file number and the page the item was listed on.
D. Property Being Refunded
Property Description (general)
Account Number (if applicable)
Amount
Property Description (general)
Account Number (if applicable)
Amount
E. Documentation Required
The Michigan Department of Treasury, Unclaimed Property Division's goal is to reunite owners or their heirs with the unclaimed
property turned over to the state when the holder was unable to locate the rightful owner. Claimants must prove ownership by
furnishing copies of your driver license (or other government picture identification) and your Social Security card. You may need to
provide additional documentation to prove ownership.
F. Affidavit
Under penalty of perjury, I certify that the information provided on this claim is true and all supporting documentation is either
original or unaltered copies of the original documents. Upon payment of this claim, I indemnify the State of Michigan and its officers
and employees from any damages, claims or losses resulting from payment of the property.
Claimant's Signature
Notarization
Co-Claimant Signature

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