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Change Of Status Request To Form Private Corporation Form. This is a Michigan form and can be use in Liquor Control Commission Statewide.
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Tags: Change Of Status Request To Form Private Corporation, LC 2099A, Michigan Statewide, Liquor Control Commission
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Michigan Department of Licensing and Regulatory Affairs
LIQUOR CONTROL COMMISSION
7150 Harris Drive, P.O. Box 30005 - Lansing, Michigan 48909-7505
CHANGE OF STATUS: REQUEST TO FORM PRIVATE CORPORATION
(Authorized by MAC R436.1103)
INSTRUCTIONS: Complete this request and return it to the Commission along with any other requested documents.
NAME OF LICENSEE: ______________________________________________________________________
TYPES OF LICENSES HELD: ________________________________________________________________
PERMITS HELD: __________________________________________________________________________
LICENSED ADDRESS: ______________________________________________________________________
Number & Street
City
State
Zip Code
NAME OF NEW CORPORATION: _____________________________________________________________
CORPORATION ADDRESS: __________________________________________________________________
Number & Street
City
State
Zip Code
The licensees state that they are forming a private Michigan Corporation and are exchanging the listed
assets for all outstanding stocks in the corporation.
ITEMIZED LIST OF ASSETS (i.e. fixtures & equipment, attach extra pages if necessary):
(Note: If the real estate is not transferred to the corporation, be prepared to submit a copy of a lease or rental agreement when you are
notified of Commission approval.)
LC-2099A Rev. 04/11
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
The licensees state that they will be the sole stockholders in this corporation and that the stock will be issued as:
Name of Stockholders
Certificate Number
Shares Issued
Date Issued
WARNING: SECTION 1003 OF ACT NO. 58, PUBLIC ACTS OF 1998, AS AMENDED, provides as follows:
A person who makes a false or fraudulent statement to the commission, orally or in writing, for the purpose of
inducing the commission to act or refrain from taking action or for the purpose of enabling or assisting a person to
evade the provisions of this act is guilty of a violation of this act and is punishable in the manner provided for in
section 909.
Further, the rules and regulations of the liquor control commission entitled, Transfer of License
provides:
No licensee shall sell or transfer his/her license, or any interest therein, without the consent of the liquor control
commission, nor shall any person or persons obtain a license in his/her/their name for the use and benefit of
another person whose name does not appear on the license.
LICENSEE SIGNATURES:
___________________________________________
Date
____________
___________________________________________
Date
____________
___________________________________________
Date
____________
___________________________________________
Date ____________
LC-2099A Rev. 04/11
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