Treasury Form 3618 (1/00) State of Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission Office Use Only Entered by: ELECTRONIC FUND TRANSFER (EFT) AUTHORIZATION FOR SPIRITS PURCHASES BY LIQUOR LICENSEE Date: Authority: MCL 436.1221(1). Completion of this form is required to establish an Electric Fund Transfer account. Instructions:  Please print or type entries.  Carefully read and complete the entire authorization form.  Mail the completed form to: Michigan Liquor Control Commission, 7150 Harris Drive, P.O. Box 30005, Lansing, MI 48909  If you have any questions about completing this form please call (517) 322-1382 No Yes  Is a change of address for the business (liquor licensee) included on this form? 1. Type of application (select only one) NEW - Select if establishing an Electronic Fund Transfer (EFT). Allow a minimum of 7 days for the EFT to begin. An EFT is in effect when you are notified by a delivery driver. Your invoice will indicate "Payment by EFT." CHANGE - Select if changing financial institution, account number, type of account, etc. Do not close your old account until this change takes place. Any change to your financial institution or account number may cause an EFT to be suspended while the change is being processed. CANCEL - Select if you want to cancel an ongoing EFT. Licensees may cancel this EFT authorization by completing and mailing this form to the address above. Do not close your old bank account until your invoice reflects the change in payment status. 2. Name of Business (as shown on liquor license) 6. Street Address (of licensee) 3. Lic.Type 5. Business ID No. 4. License No. 7. City, State, ZIP Code (of licensee) 8. Telephone Number ( 9. Name of Financial Institution 11. Street Address (of Financial Institution) ) 10. Name of Contact Person (at Financial Institution) 12. City, State, ZIP Code (of Financial Institution) 13. Telephone Number ( 14. Account Number (of licensee) 15. Routing Transit Number * (of Financial Institution) ) 16. Account Type Checking Savings * Contact your financial institution for the routing transit number, if not already known. If this is a checking account attach a voided check to this form. 17. Authorization I authorize the State of Michigan, Michigan Liquor Control Commission (MLCC) to make variable withdrawals by electronic transfer from the designated financial institution and account identified above. The amount of the withdrawals will be equal to the amount shown on my invoice for liquor spirits delivered by MLCC's Authorized Distribution Agents (ADAs). I authorize the MLCC to return money that was withdrawn from my account in error, either by electronically adjusting my account or adjusting future invoices. I understand I will be notified by the State of Michigan if adjustments are made. It is my responsibility as a liquor licensee to complete a new EFT Authorization form for MLCC if I change financial institutions or account numbers, the account is closed, the license is terminated or sold, or there are other changes affecting the account. I understand this authorization remains in effect until canceled by: (a) myself, (b) another authorized representative of this liquor licensee, (c) or the State of Michigan. Licensees may cancel this EFT at any time. I agree to comply with the National Automated Clearing House Association Rules and Regulations about electronic transfers as they exist on the date of my signature on this form or as subsequently adopted, amended, or repealed. Michigan law governs electronic funds transactions authorized by this agreement in all respects except as otherwise superseded by federal law. Please note that you are ineligible to pay by ACH if the bank account identified above is funded or otherwise associated with a foreign bank account to the extent that the payment transaction would qualify as an International ACH Transaction (IAT) under the NACHA Rules. If multiple signers are required to authorize a withdrawal of funds, all must sign this authorization form. Printed Name of Authorized Liquor Licensee Representative Signature of Authorized Liquor Licensee Representative Date The Authorized Signature must be of a person authorized to sign any and all documents required by the Michigan Liquor Control Commission under Commission Rules. LC-13 (4/11) LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Distribution: White - State; Canary - Licensee American LegalNet, Inc. www.FormsWorkFlow.com