Form 3165 - Michigan Holder Request For Refund Form - Michigan Department Of Treasury
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Michigan Department of Treasury
Treasury Use Only
3165 (Rev. 04-12)
Claim Number
Michigan Holder Request for Refund
Prepared by:
1
3
Issued under Public Act 29 of 1995. Filing is voluntary.
2
Denied
Use this form to request a refund of unclaimed property that was reported to the State of Michigan in error. Also use this
form for items that you reimbursed to the rightful owner or for which you reestablished an account. Submit a separate
request for each report year.
Holder Information
Holder's Name
Federal Employer ID Number
Telephone Number
Report Year
Total Amount of Report
Street Address
City, State and Zip Code
Claim Information
Date paid to
claimant or
Account/Reference No.
Owner's Name
Claimant's Name
Claimant's Address
acct.
Property Code
Owner's Address
Amount Paid
(If in aggregate, specify)
(Exactly as indicated on report.)
(If different from owner.)
(If different from owner.)
reactivated.
(include proof)
a.
b.
c.
d.
If your refund is due to a reporting error, explain here.
TOTAL
REFUND
Holder Certification
I certify that the properties listed above which were included in the Report of Unclaimed Property or
Subscribed and sworn to before me the _____ day of ______________ , 20 ______.
Securities filed for the report year in item 1d have been paid to the rightful owner or claimant. Upon
payment of this request, I agree to hold the state harmless from all claims and loss, demands, costs and
____________________________________________________________________
other expenses which the state may sustain by reason of turning over the property to the holder and by its
(Notary Signature)
further refusal to pay the property to any other person.
Notary Public in and for the county of ___________________________ Michigan.
Signature of Holder Representative
Date
My commission expires ____________________.
Print or Type Representative's Name
Date
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