2011, Michigan Holder Transittal For Annual Report Of Unclaimed Property 30756 2011f 2592 7
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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 le is punishable by ne.
This transmittal must accompany your annual report whether you are ling on paper, CD ROM, or some other method. If your annual report does not
meet Treasury specications, 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 le a Report of Unclaimed Property last year?
Yes No Yes No, explain: _________________________________________
12. What media type are you ling 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 (dened 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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