Print Form Michigan Department of Licensing and Regulatory Affairs MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 Lansing, Michigan 48909-7505 FOR MLCC USE ONLY Request ID # Business ID # AFFIDAVIT OF SOURCE OF FUNDS [Authorized by R 436.1105] _________________________________________________________________________________________________ Applicant or Licensee Name: Name of Money Lender: Source of Funds, current account balance & date account was opened: Enter previous 2 years annual gross sales: 20 20 $ $ If source of funds, is an individual, list name of individual, give relationship, (brother, friend, etc), and list reasons why you are obtaining funds from this source: Do you hold any position, either by appointment or election, which involves the duty to enforce any penal law of the United State of America, or the penal laws of the State of Michigan, or any penal ordinance or resolution of any municipal subdivisions of the State of Michigan.? Yes No Do you hold any class of license for the manufacture or sale of alcoholic beverages at wholesale in Michigan, or any interest (stockholder/member) in any class of license for the sale of alcoholic liquor in Michigan which would be in conflict with the granting of this license? Yes No I understand that the falsification of the information on this form, or any false statements made may constitute grounds for denial of this application or revocation of the permit issued. (Signature of Money Lender) Subscribed and sworn before me this_________ day _____________________ Notary Public, ______________________________________County, Michigan My Commission Expires: __________________________________________ LC-1126 (Rev. 04/11) Authority: R 436.1105 Completion: Mandatory Penalty: No License and/or Permit 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