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Michigan Department of Treasury 5743 (02-21) Notice of Intention to Claim Interest in Foreclosure Sales Proceeds Issued under authority of Public Act 206 of 1893; Section 211.78t. Beginning with 2021 foreclosure sales and transfers, a person that intends to make a claim for excess sales proceeds must complete and return this notarized notice to the Foreclosing Governmental Unit by July 1 in the year of foreclosure. This notice must be delivered via certified mail, return receipt requested, or by personal service. Completing and returning this form evidences an intent to make a future claim but is not itself a claim for sales proceeds. PART 1: APPLICANT INFORMATION Claimant Last Name or Business Name Claimant First Name Middle Initial Claimant’s Address to be used for Service (Street Number, City, State, ZIP Code) Claimant’s Telephone Number Claimant’s E-mail Address PART 2: PROPERTY IDENTIFICATION County Local Taxing Municipality Foreclosure Year Parcel Address (Street Number, City, State, ZIP Code) Local Parcel Number PART 3: EXPLANATION OF INTEREST I hereby claim an interest in the above parcel, as of the foreclosure date, due to the reason(s) selected below: Warranty Deed Dated: Recorded in Liber/Page: Quit Claim Deed Dated: Recorded in Liber/Page: Mortgage Dated: Amount: Recorded in Other Lien Dated: Amount: Nature of Recored in I know of the following other interests in this property, which were in effect immediately prior to foreclosure: PART 4: CERTIFICATION AND NOTARY I hereby swear that the above information is true and correct in relation to the subject property Claimant’s Signature Date Subscribed and sworn to before me by Applicant on the following date: Notary’s Signature Commission Expiration Notary State of Authorization Notary County of Authorization Notary Acting in County FORECLOSING GOVERNMENTAL UNIT RECEIPT ACKNOWLEDGMENT FGU Staff Signature of Receipt FGU Staff Printed Name Date of Receipt