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Reset Form Michigan Department of Treasury 3433 (Rev. 11-10) Unclaimed Property Inquiry Issued under authority of Public Act 29 of 1995. Read the instructions on page 2 before completing this form. PART 1: CLAIMANT/PROPERTY OWNER INFORMATION Property Owner’s Name as it Appears on Unclaimed Property Web Search Property Owner’s Social Security or Federal Employer Identification Number Claimant Name Claimant’s Social Security or Federal Employer Identification Number (if different) Relationship to Property Owner Current Address (Number and Street or RR#) Property Number(s) City, State, ZIP code Daytime Telephone Number PART 2: FORMER ADDRESSES. List all former Michigan addresses used by the property owner. Street Address City, State, ZIP Code PART 3: DECEASED PROPERTY OWNER. Refer to instructions for list of required documentation. 1. Did the Decedent have a Will? Yes No 2. Did the Decedent have a Trust? Yes No 2b. Is the Trust open? Yes No 3. Did the Decedent have a Probated Estate? Yes No 3b. Is Probated Estate open? Yes No PART 4: CLAIMANT CERTIFICATION Under penalties of perjury, I certify that the information provided on this inquiry form is true to the best of my knowledge. Upon payment of this claim, said claimant will indemnify and hold harmless the State of Michigan, officers and employees from any damages, claims or losses of any kind resulting in payment of the property being claimed. SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF , NOTARY PUBLIC SIGNATURES OF CLAIMANTS 20 COUNTY, STATE MY COMMISSION EXPIRES Return completed form along with a copy of a picture I.D., social security card, and required documentation (see page 2) to: www.michigan.gov/unclaimedproperty Office Use Only: Approval: 1.____ 2.____ 3.____ 4.____ 5.____ Unclaimed Property Division Michigan Department of Treasury P.O. Box 30756 Lansing, MI 48909 Allow 120 days for processing. 3433, Page 2 Instructions for Form 3433, Unclaimed Property Inquiry FORM INSTRUCTIONS Part 1. Complete applicable fields. Part 2. List all former Michigan addresses used by the property owner, including P.O. Boxes. Part 3. If property owner is deceased, answer all questions and provide required documentation. Part 4. Sign and have your signature notarized by a Notary Public. REQUIRED DOCUMENTATION Individual Property Owner Submit copies of the following documents: • Picture ID (driver’s license or identification card) • Social security card • If your name differs from how it appears on the Unclaimed Property Web site, submit legal documentation supporting the name change (e.g. marriage certificate, adoption papers, divorce decree, etc.). Claimant Other Than Property Owner Parent on Behalf of a Minor Submit a copy of the minor child’s birth certificate and social security card. Guardian, Conservator, Trustee or Legal Representative Submit a copy of the court documents or other signed legal documents giving you authority to act on the property owner’s behalf. If providing a Durable Power of Attorney, submit a medical provider statement indicating property owner is unable to sign his or her name. Deceased Property Owner All questions in Part 3 must be answered in order to process your inquiry. All claims on behalf of deceased owners must include the following documentation (originals will not be returned): • Copy of Death Certificate • Proof of your relationship to decedent (obituary, birth certificate, marriage license) Documentation required: 1. Did decedent have a Will? If yes, provide copy of Will. 2. Did decedent have a Trust? If yes, provide a copy of the Trust. 2b. Is the Trust open? If yes, the Trustee is entitled to claim the property on behalf of the Trust, the Trustee will need to complete this form. 3. Did decedent have a Probated Estate? If yes, proceed to 3b to determine what documents are required: 3b. Is the Estate currently open? • If yes, send a current copy (dated within last 12 months) of your Letters of Authority issued by the probate court certifying your appointment. • If no, send a copy of the Opening Petition, a copy of the Final Estate Order listing the heirs and the percentage or amount received from the Estate, and a list of current addresses of all heirs. Business Property Owner Submit copies of the following documents: • Business card • Articles of Incorporation or DBA showing ownership of the business and name changes. • List of subsidiaries that entity can claim on behalf of. • Documentation showing authorization for you to act on behalf of the business entity shown as the original property owner. Closed (But Not Sold) Entities • Final Federal tax return filed including Schedule C Sold Entities • Buy/sell agreement showing who owned the accounts receivable at the close of sale. Dissolved Entities • • Dissolution papers showing who the shareholders were at the time of the dissolution. If corporation did not file for dissolution with the State of Michigan, submit the automatic dissolution and a copy of the final corporate Federal tax return, including Schedule K. List of current addresses of all shareholders. You may also be required to complete a formal claim form and provide additional documentation. Allow 120 days for processing from the date form was mailed.