NOTICE OF WITHHOLDING TO MUNICIPALITY
To:  Name and Address of Municipal Treasurer ______________________________________ ______________________________________ ______________________________________ Name and Address of Named Insured_________    ______________________________________ ______________________________________ Insured Property Description________________ ______________________________________ ______________________________________ Insured Property Description________________ ______________________________________ ______________________________________		From:  Name, Company name and address, dept. ______________________________________ ______________________________________ ______________________________________ Name and Address of Mortgagee ____________ ______________________________________ ______________________________________ Policy No.______________________________ Claim No. ______________________________ Date of Loss ____________________________ Amount Withheld  ________________________
In accordance with Michigan Law (PA495, 386, 216 and 217) this Company is withholding a portion of the amount payable for fire or explosion loss to the insured property shown above.  If the municipality fall within the scope of PA 217, the withholding will be for loss by fire, explosion, vandalism, malicious mischief, wind, hail, riot or civil commotion.   You will be deemed to have received this notice of withholding two business days after the date of mailing by this Company.   We will forward to you the withheld amount upon receiving a request from the chief fire official (or other authorized representative) that the insured real property violates existing health and safety standards.  This affidavit must be delivered or postmarked within 15 days after you receive this notice of withholding.  In determining the 15 days, the date of receipt of this notice by you will be excluded and the date of receipt by us will be included.  If the 15th day falls on a Saturday, Sunday or holiday, it will be considered to be the next business day.   This affidavit should be mailed to us at the address shown above.   Copies of the affidavit must also be sent to:   a.        the insured; b.       The first mortgagee; and c.        in the case judgments, the court in which judgment was entered.   If we do not receive a request within the prescribed time limits, you will no longer be entitled to claim the withheld funds.  The withheld funds will immediately be sent to the named insured even if they are still in our possession when we receive a request.