Print Form 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