Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission (MLCC) Constitution Hall - 525 W. Allegan, Lansing, MI 48933 Mailing address: P.O. Box 30005, Lansing, MI 48909 Toll-Free: 866-813-0011 - www.michigan.gov/lcc MLCC Licensee Name:Month & Year:MLCC License Number:Fax number:Phone:Email: LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. LCC-3859 (02-18) Date Signature of Licensee Print Name of Licensee & TitleI certify that the information contained in this form is true and accurate to the best of my knowledge and belief. I also understand that providing false or fraudulent information is a violation of the Liquor Control Code pursuant to MCL 436.2003.Invoice NumberCheck Box If Wholesaler Paying TaxInvoice DateSales at Licensed Premises/Taproom (Totals Only):TOTAL MICHIGAN SALES:Sales to Other States:Sales to Michigan Retailers (Totals Only):Sales to Michigan Wholesalers: Wholesaler/Retailer Name & License Number Pursuant to MCL 436.1409(2) and Administrative Rule R 436.1621(3), a Brewer or Microbrewer licensee that chooses to designate a Wholesale licensee to pay its taxes must use the Manufacturer Tax Designation Notification Form (LCC-3900) to designate a Wholesale licensee to pay the tax on beer sold to retail licensees.240 A Brewer or Micro Brewer licensee must first notify the Commission and the Wholesale licensee of the designation by April 1.240Page 1 of 2Michigan Brewer or Micro Brewer's Monthly Report of Sales (LCC-3859)Computer reports that show this information in the same sequence may be submitted in lieu of this report. Contact 517-284-6260 for more information. Attach a copy of this report to the Michigan Beer Tax Report (LCC-3803) and submit to the address at the top of this form. BarrelsBarrel1/2 bbl.1/4 bbl.1/6 bbl.Cases (Enter Additional Sizes/Quantities)24/1224/16OuncesFirkinGrowlerSales to Michigan Wholesalers Who Paid Tax: American LegalNet, Inc. www.FormsWorkFlow.com Michigan Brewer or Micro Brewer's Monthly Report of Sales (LCC-3859) - Page 2MLCC Licensee Name:Month & Year:MLCC License Number: Invoice NumberCheck Box If Wholesaler Paying TaxInvoice Date Wholesaler/Retailer Name & License Number LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. Page 2 of 2LCC-3859 (02-18) BarrelsBarrel1/2 bbl.1/4 bbl.1/6 bbl.Cases (Enter Additional Sizes/Quantities)24/1224/16OuncesFirkinGrowler American LegalNet, Inc. www.FormsWorkFlow.com