Michigan Department of Licensing and Regulatory Affairs MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505 Phone 517-322-6380 MICHIGAN BREWERIES MONTHLY REPORT OF SALES Brewery Name Wholesaler Name & Address Month – Year Invoice Number Invoice Date Cases – enter additional sizes & quantities 24/12 24/16 12/40 Kegs ½ ¼ Sales to Michigan Wholesalers Sales to Michigan Retailers (total only) Sales to Michigan Consumers (total only) Subtotal Michigan Sales Sales to Other States TOTAL SALES 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, LC-803 and mail to the above address.) Signature of Authorized Official ___________________________________ Title _____________________________ Date _______________ LC-3859 (Rev. 07/11) 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