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 CLAIM FOR RECOVERY OF BEER, MIXED SPIRIT DRINK OR WINE TAXES _________________________________________________________________________________________________ IMPORTANT NOTICE • • • • Any person who makes a false or fraudulent statement to the Commission to induce the Commission to act or to refrain from acting shall be guilty of a violation of the Liquor Control Act and subject to a fine, suspension or revocation of the license. Filing of this claim is voluntary. However, failure to file this claim will result in no action being taken by the Commission. Please submit separate claims for Beer taxes, Mixed Spirit Drink taxes, and for Wine taxes. Upon approval of this claim, credits are issued to tax-paying licenses; refunds are issued to licensees who do not pay Beer, Mixed Spirit Drink, or Wine taxes. 2. Business Telephone 1. Name and Address of Licensee 3. License Type and Number 4. Check only ONE Submit separate claims for beer, mixed spirit drink or wine. Claim for Beer Tax Claim for Spirit Drink Tax Claim for Wine Tax 5. Check type of claim and follow instructions shown below for each. A. TAX EXEMPT SALE TO MILITARY xxxxxxxxx xxxxx INSTALLATION OR INDIAN RESERVATION D. OVERAGED BEER, MIXED SPIRIT DRINK OR WINE xxxxxxxxNOT SALEABLE • Claims must be made within 3 months of sale. • Itemize overaged product on the back of this form. • Itemize shipments on the back of this form. • • Attach applicable sales invoices. Product for which a claim is submitted shall be destroyed by prior Commission Order or removed from Michigan. B. TAX EXEMPT SHIPMENT FOR RESALE & xxxxxxCONSUMPTION OUTSIDE MICHIGAN E. UNINSURED LOSS OF BEER, MIXED SPIRIT DRINK, OR xxxxxxxx WINE TAXES PAID • Itemize shipments on the back of this form. • • Attach applicable invoices which show original tax payment and out-of-state shipment. Claims must be made within 3 months of the date of occurrence or delivery. • Claims for theft of product will not be processed. • Itemize losses on the back of this form. • It is the responsibility of the claimant to prove that a loss occurred and the amount of the loss. All claims will be investigated. • Product for which a claim is submitted shall be destroyed by prior Commission Order or removed from Michigan. • A credit or refund is available only to the person who paid the tax. C. ADJUSTMENT OF BEER, MIXED SPIRIT xxxxxx xxxx DRINK, OR WINE TAXES DUE TO SHIPPING xxxxxOR BILLING ERRORS • Itemize shipments on the back of this form. • Attach clearly marked billing/credit invoices which show errors and corrections. 6. If you checked UNINSURED LOSS OF BEER, MIXED SPIRIT DRINK, OR WINE TAXES PAID, Section E above, you must also answer these questions: • Was the loss or damage incurred the result of any action by you or your agent? Yes No Have you made or will you make, any other claim under any other law or to any insurance agency for recovery of these taxes? • Yes No • Was the product in your possession for resale purposes? • Describe loss • Date of loss ______ / ________/ ________ ? Location of loss _____________________________________________ Fire Flood Casualty Yes No Other (explain) __________________________________________ I swear that all of the information, including the itemized description on the back of this Claim (and any subsequent pages) is true and is submitted in order to receive a refund or credit for taxes paid. Signature ________________________________________ Title ___________________________________ Date _______________ LCMW-811 (Rev. 04/11) Authority: MCL 436.1301, 436.1409 Completion: Mandatory Penalty: No Credit 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 6. ITEMIZED DESCRIPTION This page may be photocopied if necessary. Please attach any copies to the back of this claim form. You may also attach a summary report which contains the same information. TOTAL LITERS OF MIXED BOTTLE SIZE BRAND NAME OF PRODUCT NO. OF BOTTLES SPIRIT DRINK OR WINE OR BARRELS OF BEER TOTAL TAX PAID INVOICE NUMBER INVOICE DATE 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. PLEASE SHOW TOTALS For MLCC Use Only TOTAL TAX PAID FOR THIS CLAIM BEER: CREDIT ISSUED APPROVED BY WINE: REFUND ISSUED DATE MIXED SPIRIT DRINK: American LegalNet, Inc. www.FormsWorkFlow.com