Michigan Holder Transmittal For Annual Report Of Unclaimed Property Form - 2016

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Michigan Department of Treasury

2011 (Rev. 04-16)

Mail to:

Michigan Holder Transmittal for

Michigan Department of Treasury

Annual Report of Unclaimed Property

Unclaimed Property

PO Box 30756

Issued under the authority of P.A. 29 of 1995, Filing is mandatory.

Lansing, MI 48909

Failure to file is punishable by fine.

This transmittal must accompany your annual report whether you are filing on paper, CD ROM, or some other method. If your annual report does not

meet Treasury specifications, as indicated in the Manual for Reporting Unclaimed Property, it will not be accepted.

1. Report Year

GENERAL INFORMATION

2. Holder’s Name

3. Federal Employer ID Number

4. State of Incorporation

5. Address

6. County

7. Date of Incorporation

8. City, State, Zip Code

9. Primary Business Activity

10. Did you exercise due diligence this report year?

11. Did you file a Report of Unclaimed Property last year?

Yes

No, explain: _________________________________________

12. What media type are you filing with Form 2011?

CD Rom

Form 1223

Other (specify) _____________________________

*Do not mix media types for the same report.

13. Report Type

Annual

VDA

First

Audit

Other

REPORTING REQUIREMENTS (Attach payment here.)

14. You must report and submit all property (defined in General Instructions) in your custody that belongs to someone else and has

gone unclaimed.

a. Total number of safety deposit boxes reported (if applicable). ................................................................

b. Total number of shares of stock/mutual funds (if applicable). ..................................................................

c. Total amount paid with this transmittal. ....................................................................................................

*Make checks payable to “State of Michigan.”

Check attached.

Electronic Payment Receipt Attached

CERTIFICATION

I declare under penalties imposed by P.A. 29 of 1995, as amended, that I have examined this report and to the best of my knowledge it is true and complete.

15. Print Contact Name

Telephone Number

E-mail Address

Fax Number

16. Signature

17. Title

18. Date

If you are a successor, attach a separate sheet listing the names and last known addresses of all previous holders of the property being reported. If

you have changed your name during the reporting period, attach a separate sheet listing all prior names.

Treasury Use Only

Holder ID

Report