2011, Michigan Holder Transittal For Annual Report Of Unclaimed Property 30756 2011f 2592 7
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Reset Form Michigan Department of Treasury 2011 (Rev. 04-16) Mail to: Michigan Department of Treasury Unclaimed Property PO Box 30756 Lansing, MI 48909 Michigan Holder Transmittal for Annual Report of Unclaimed Property Issued under the authority of P.A. 29 of 1995, Filing is mandatory. 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? Yes 11. Did you file a Report of Unclaimed Property last year? No 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 Stock ID Import Batch
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