Form 2196 - Request For Bottle Deposit Fund Reimbursement (For Retailers And Dealers) - 2012

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Michigan Department of Treasury

Report Year

2196 (Rev. 09-12)

2012

Request for Bottle Deposit Fund Reimbursement (for Retailers and Dealers)

Issued under authority of Public Act 148 of 1989.

INSTRUCTIONS: Under Public Act 148 of 1989, Michigan retailers and dealers who sell beverages in returnable

containers can request compensation for some of the costs for handling the empty returnable containers.

Reimbursements are drawn from a fund created by manufacturers and distributors who collect more deposits than they

redeem. This report is due on or before June 1, 2013. Reports postmarked after June 1, 2013 will not be honored.

Treasury will not issue a check for less than $1. This information will be reported to the Internal Revenue Service.

Form 1099-MISC will be issued for reimbursements of $600 or more. Do not file this form if you did not make retail

sales in Michigan during 2012.

2. Account Number used to file your sales tax return

1. Corporate Company Name (include, if applicable, Corp., Inc., P.C., L.L.C., etc.)

Business Name, Assumed Name or DBA (if used)

Business Address (Number and Street or P.O. Box)

City, State, ZIP Code

Type of Business (Check appropriate Box)

Individual/Sole Proprietor

Corporation

Partnership

Other:

Number of Containers

4 3. Report actual number of empty returnable containers handled during 2012? Do not report the

dollar value of the containers. For example, if you handled 5,000 containers during 2012, report the

quantity of 5,000, not the value of the deposits ($500). Quantity must be actual, not estimated.

4. Source of information used to determine number of empty returnable containers handled (check one).

3. Other (explain):

1. Invoices

2. Cash register receipts

5. Are you also an originator of deposits? “Originator” means you have not paid a deposit to another manufacturer or distributor -- the deposit started with you.

Yes (1)

No (0)

The Initiated Law of 1976 defines “returnable container” and “empty returnable container” as follows:

”Returnable container” means a beverage container upon which a deposit of at least 10 cents has been paid, or is required to be paid upon removal

of the container from the sale or consumption area, and for which a refund of at least 10 cents in cash is payable by every dealer or distributor in this

state of that beverage in beverage containers . . .

“Empty returnable container” means a returnable container which contains nothing except the residue of its original contents.

The Michigan Department of Treasury interprets the word “handled” as found in Public Act 148 of 1989 to mean an empty returnable container which

a consumer has returned to a dealer for a deposit refund. It also includes empty returnable containers which, when full, were sold by a dealer for con-

sumption on the premises but upon which no deposit was collected or a refund given to a consumer.

AUTHORIZATION

The above information may be used to issue forms 1099 and is intended to substitute for form W-9. I certify that the above information is true and

complete for its intended purposes.

Owner or Officer Signature

Print or Type Name of Owner or Officer

Telephone Number

Date

Preparer Signature

Print or Type Name of Preparer

Telephone Number

Date