Form 3164 - Michigan Annual Report Of Unclaimed Shares Of Stock/mutual Funds

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Michigan Department of Treasury
3164 (Rev. 04-12)
Michigan Annual Report of Unclaimed Shares of Stock/Mutual Funds
Issued under Public Act 29 of 1995. Filing is mandatory.
Page _____ of _____
Holder Name
Report Year
This form must be attached to the Michigan Holder Transmittal (Form 2011).
If you are reporting ten or more properties, you must file your report on
Federal Employer ID Number
Report Number
diskette/CD-ROM instead of paper (see instructions).
1
2
3
Properties. Complete all items for each property. You must report all available owner information.
a. Issue Name
b. P. Type
c. Owner's Name (Last, First, MI), Last Known Address
d. Rel. Code
e. Social Security No. or FEIN
f. CUSIP Number
g. Date of Last
Activity
(YYYYMMDD)
h. Description
i. No. of Shares
j. If interest bearing, enter %.
Periodic Payments (from/to)
l. Con't
a. Issue Name
b. P. Type
c. Owner's Name (Last, First, MI), Last Known Address
d. Rel. Code
e. Social Security No. or FEIN
f. CUSIP Number
g. Date of Last
Activity
(YYYYMMDD)
h. Description
i. No. of Shares
j. If interest bearing, enter %.
Periodic Payments (from/to)
l. Con't
a. Issue Name
b. P. Type
c. Owner's Name (Last, First, MI), Last Known Address
d. Rel. Code
e. Social Security No. or FEIN
f. CUSIP Number
g. Date of Last
Activity
(YYYYMMDD)
h. Description
i. No. of Shares
j. If interest bearing, enter %.
Periodic Payments (from/to)
l. Con't
a. Issue Name
b. P. Type
c. Owner's Name (Last, First, MI), Last Known Address
d. Rel. Code
e. Social Security No. or FEIN
f. CUSIP Number
g. Date of Last
Activity
(YYYYMMDD)
h. Description
i. No. of Shares
j. If interest bearing, enter %.
Periodic Payments (from/to)
l. Con't
a. Issue Name
b. P. Type
c. Owner's Name (Last, First, MI), Last Known Address
d. Rel. Code
e. Social Security No. or FEIN
f. CUSIP Number
g. Date of Last
Activity
(YYYYMMDD)
h. Description
i. No. of Shares
j. If interest bearing, enter %.
Periodic Payments (from/to)
l. Con't
Complete this item only on the last page of the report.
$
Enter the total dollars you are submitting with this report.

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