Print Form Michigan Department of Licensing and Regulatory Affairs LIQUOR CONTROL COMMISSION 7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505 WINE/MIXED SPIRIT DRINK WHOLESALERS MONTHLY REPORT Name: License No. Date Reported (month-year) Address (street and city): Business Phone: ( ) INSTRUCTIONS: All wholesalers who receive wine or mixed spirit drinks from an Outstate WHO MUST FILE: Seller of Wine, an Outstate Seller of Mixed Spirit Drink, or a Mixed Spirit Drink Manufacturer. 1. This report must be filed on or before the 15th day of each month for all sales for the preceding month. THIS REPORT MUST BE FILED EVEN IF NO TRANSACTIONS HAVE OCCURRED. 2. Enter heading information requested above. 3. Attach copies of all invoices for WINE & MIXED SPIRIT DRINKS received from an Outstate Seller of Wine, or an Outstate Seller of Mixed Spirit Drink Manufacturer. YOU MUST SEPARATE THE TWO TYPES OF INVOICES. PLEASE COMPLETE THE FOLLOWING INFORMATION: ______ Total number of invoices being submitted. Check here if no Wine transactions this month ________. Check here if no Mixed Spirit Drink transactions this month _______. Wine or Mixed Spirit Drinks purchased from a Michigan Wholesaler or a Michigan Winery do not have to be reported. WARNING: Licensees who fail to submit a required report, or who file a false report, may have their license suspended or revoked. I declare that the information contained in this report is correct to the best of my knowledge. Signature of Authorized Agent LC-155 (Rev. 04/11) AUTHORITY: MCL 436.1301, R436.1720(5) COMPLETION: Mandatory PENALTY: License suspension/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