Michigan Department of Licensing and Regulatory Affairs MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) Constitution Hall - 525 W. Allegan, Lansing, MI 48933 Mailing Address: P.O. Box 30005 - Lansing, Michigan 48909-7505 Toll Free # 866 813-0011 BEER SOLD TO MICHIGAN WHOLESALERS SOLD BY (Brewery Name) SOLD TO (Wholesaler Name & Complete Address) Month ­ Year INSTRUCTIONS 1. Submit this form, or an approved computer printout, with the Michigan Beer Tax Report (LC 803) to the above address. 2. Complete the heading information. A separate form must be completed for each wholesaler. 3. Enter the pack size in the spaces provided at the top of each column. Example: 24/12 oz is a 24 pack of 12 oz. beer. 4. The total of all sales to Michigan Wholesalers must balance with the total on the Michigan Beer Tax Report (LC 803). 5. COMPUTER REPORTS ­ A computer report that shows the SAME information requested above may be submitted in lieu of this report. Verify the format with the Financial Management Division prior to use. DATE Invoice Number 24/12 oz. Cases ­ enter additional sizes & quantities ½ Kegs ¼ TOTALS Note: Computer reports which show this information in the same sequence may be submitted in lieu of this report. Contact (517) 322-6380 for more information. I DECLARE THAT THIS REPORT IS CORRECT (attach a copy to the Michigan Beer Tax Report and mail to the above address.) Signature of Authorized Official ___________________________________ Title _____________________________ Date _______________ LCC-3886 (Rev. 06/14) AUTHORITY: MCL 436.1409; R 436.1621 COMPLETION: Mandatory PENALTY: Fine &/or License Revocation LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. American LegalNet, Inc. www.FormsWorkFlow.com