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 WHOLESALER MONTHLY REPORT OF PURCHASES (LC-155) Check only one Beer Wine Mixed Spirit Drink Business Name: Address: Phone: Fax number: License Number: City, State & Zip Code: Email: Month & Year Reported: INSTRUCTIONS: Who must file: All wholesalers that receive beer, wine, or mixed spirit drink from an Outstate Seller of Beer, Outstate Seller of Wine, an Outstate Seller of Mixed Spirit Drink, Michigan Brewery, Michigan Winery, or Michigan Mixed Spirit Drink Manufacturer. 1. Enter heading information requested above. 2. Submit a separate report for Beer, Wine, or Mixed Spirit Drink and attach the appropriate invoices to each report submitted. 3. Attach copies of all purchase invoices for BEER, WINE, ORMIXED SPIRIT DRINK received from an Outstate Seller, a Michigan Brewery, a Michigan Winery, or a Michigan Mixed Spirit Drink Manufacturer. 4. This report must be filed on or before the 15th day of each month for all purchases for the preceding month. THIS REPORT MUST BE FILED EVEN IF NO TRANSACTIONS HAVE OCCURRED PLEASE COMPLETE THE FOLLOWING INFORMATION: Total number of invoices being submitted Check here if no purchase transactions this month WARNING: Licensees that fail to submit a required report or that file a false report may have their license suspended or revoked. I 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. Print Name of Licensee & Title Signature of Licensee Date LC-155 (02-16) 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