Form 165 - Annual Return For Sales, Use And Withholding Taxes Page 2
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2Form 165, Page 2
Taxpayer's Business Name
Account Number
Type of Business Ownership (check one only)
Michigan Corporation
Individual
Non-Michigan Corporation
Trust or Estate (Fiduciary)
Subchapter S
Husband - Wife
Subchapter S
Joint Stock Club or Investment Company
General Partnership
Social Club or Fraternal Organization
Limited Partnership
Other (Explain)
Limited Liability Company Taxed As:
Individual
Partnership
C Corporation
S Corporation
Disregarded Entity
Enter the reason for amending return. Include your account number on each page being submitted. (Required)
Signature (you are required to complete all information requested below)
I declare under penalty of perjury that this return
I declare under penalty of perjury that this return is true and complete to the best of my knowledge.
is based on all information of which I have any
By checking this box, I authorize Treasury to discuss my return with the designated preparer.
knowledge.
Signature of Taxpayer's Offical Representative (must be an Owner, Officer, Member, Manager, or Partner)
Designated Preparer's Signature, Address, Telephone
and ID Number
Print Offical Representative's Name
Date
Offical Representative's Title (Owner/Officer/Member/Manager/Partner) (Required)
Telephone Number
Taxpayer's FEIN or Social Security Number
Mailing Instructions:
If sending an amended annual return, check the amended return box on page 1 of this return, and refer to
page 6 of the SUW Instruction Book (Form 78) for amended return mailing addresses and other instructions.
If enclosing payment with your annual return, mail to:
Michigan Department of Treasury
Department 78172
P.O. Box 78000
Detroit, MI 48278-0172
If requesting a credit to your account (amount on line 23) or a refund (amount on line 24), mail to:
Michigan Department of Treasury
P.O. Box 30779
Lansing, MI 48909
If no payment is enclosed with your annual return, mail to:
Michigan Department of Treasury
Lansing, MI 48930
is a secure Web site designed specifically to protect your tax information. Use this Web
site to check the status of your Sales, Use, and Withholding transactions and ask specific questions about your account.
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