Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission (MLCC) Constitution Hall - 525 W. Allegan, Lansing, MI 48933 Mailing address: P.O. Box 30005, Lansing, MI 48909 Toll-Free: 866-813-0011 - www.michigan.gov/lcc Michigan Mixed Spirit Drink Tax Report (LC-MW-891) MLCC Licensee Name:Month & Year:MLCC License Number:Address:City, State & Zip Code: Fax number:Phone:Email: LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. LC-MW-891 (03-18) Date Signature of Licensee Print Name of Licensee & TitleI certify that the information contained in this form is true and accurate to the best of my knowledge and belief. I also understand that providing false or fraudulent information is a violation of the Liquor Control Code pursuant to MCL 436.2003. Instructions: 1. Locate the appropriate pack size and enter total cases sold under "Total Cases" column. 2.Use the blank boxes for descriptions of and liters per case for pack sizes that are not preprinted on the form. The liters per case amount should be calculated to two places to the right of the decimal point (e.g. 10.75). 3.Attach all invoices and supporting documents. 4.Sign and date the form. 5.Pay the total due calculated. Make checks payable to State of Michigan/MLCC. 6.For questions, please call 517-284-6279. Total Payment Due:DUE DATE: The 15th of the month following the month being reported. This report must be filed each month whether or not any transactions have occurred. Reports or payments postmarked after the 15th day of the reporting period will be subject to a $25.00 late charge and 1% interest.Less MLCC Authorized Credit:Penalty Payment(s): Make Check Payable to State of Michigan/MLCC For MLCC Use Only - Leave Blank (MLCC Fee Code 4026) When calculating the tax owed, enter the amount of any MLCC authorized credits to be subtracted . Taxpayers must have MLCC approval prior to taking a credit on the tax report. Enter any penalties that you owe.Pack SizeLiters Per CaseNumber of CasesTotal Liters Pack SizeLiters Per CaseNumber of CasesTotal Liters 24/200 mL24/355 mL24/375 mL12/750 mL12/1 Liter6/1.75 LitersSubtotal A: Subtotal B:Total Liters (Subtotal A + Subtotal B):X $0.48 Tax = American LegalNet, Inc. www.FormsWorkFlow.com