Form 3167 - Michigan Inventory Report Of Unclaimed Property Safe Deposit Box Contents
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Michigan Department of Treasury
3167 (Rev. 04-12)
Michigan Inventory Report of Unclaimed Property Safe Deposit Box Contents
Issued under Public Act 29 of 1995. Filing is mandatory.
Attach one copy of this list of contents to your the Michigan Holder Transmittal (Form 2011) along with
Holder Name
Michigan Annual Report of Unclaimed Cash and Safe Deposit Boxes (Form 1223) or CD-ROM when it is
Page _____ of _____
reported to the State of Michigan. Report only one safe deposit box per page (a copy of the inventory should
Federal Employer ID Number
Report Year
be included in each box). Keep one copy for your records. See instructions for reporting specific property.
Owner Identification and Costs
Owner's Name (if more than one, list all)
Social Security No. or FEIN
Enter the type and amount of fees for this deposit box only.
Type
Amount
Owner's Address
Safe Deposit Box No.
Branch Where Property Was Held
Date of Abandonment
Itemized Description of Contents by Category
Authorized Bank Officials Signature
Authorized Bank Officials Signature
Treasury Use Only
Inventoried By
AUPD Approval
Date Inventoried
Date Box Opened
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