Form 1223 - Michigan Annual Report Of Unclaimed Cash And/or Safe Deposit Boxes - 2012

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Michigan Department of Treasury
1223 (Rev. 04-12)
Michigan Annual Report of Unclaimed Cash and/or Safe Deposit Boxes
Issued under Public Act 29 of 1995. Filing is mandatory.
Page _____ of _____
Attach this form to the Michigan Holder Transmittal (Form 2011). Complete this report
Holder Name
Report Year
for cash items and for safety deposit box contents only. All items less than $50 may be
reported in aggregate (see aggregate filing instructions). If you are reporting more than ten
Federal Employer ID Number
Report Number
properties, you must submit your report on diskette/CD-ROM. See instructions for
1
2
3
magnetic filing. Report securities separately (Form 3164).
Properties. Complete all items for each property. You must report all available owner information.
a. Property Description
b. P. Type
c. Owner's Name (Last, First, MI), Last Known Address
d. Rel. Code
e. Social Security No. or FEIN
g. Date of Last
f. Safekeeping Fees
Activity
(Enter Below)
(YYYYMMDD)
h. Identifying Number
i. Quantity
j. If interest bearing, enter %.
Type
Fees Owed
k. Amount Remitted
DR
$
$
a. Property Description
b. P. Type
c. Owner's Name (Last, First, MI), Last Known Address
d. Rel. Code
e. Social Security No. or FEIN
g. Date of Last
f. Safekeeping Fees
Activity
(Enter Below)
(YYYYMMDD)
h. Identifying Number
i. Quantity
j. If interest bearing, enter %.
Type
Fees Owed
k. Amount Remitted
DR
$
$
a. Property Description
b. P. Type
c. Owner's Name (Last, First, MI), Last Known Address
d. Rel. Code
e. Social Security No. or FEIN
g. Date of Last
f. Safekeeping Fees
Activity
(Enter Below)
(YYYYMMDD)
h. Identifying Number
i. Quantity
j. If interest bearing, enter %.
Type
Fees Owed
k. Amount Remitted
DR
$
$
a. Property Description
b. P. Type
c. Owner's Name (Last, First, MI), Last Known Address
d. Rel. Code
e. Social Security No. or FEIN
g. Date of Last
f. Safekeeping Fees
Activity
(Enter Below)
(YYYYMMDD)
h. Identifying Number
i. Quantity
j. If interest bearing, enter %.
Type
Fees Owed
k. Amount Remitted
DR
$
$
a. Property Description
b. P. Type
c. Owner's Name (Last, First, MI), Last Known Address
d. Rel. Code
e. Social Security No. or FEIN
g. Date of Last
f. Safekeeping Fees
Activity
(Enter Below)
(YYYYMMDD)
h. Identifying Number
i. Quantity
j. If interest bearing, enter %.
Type
Fees Owed
k. Amount Remitted
DR
$
$
Complete this item only on the last page of the report.
Total: This page only
$
Enter the total dollars you are submitting with this report.
$

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