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 REAL ESTATE OWNERSHIP STATEMENT INSTRUCTIONS: To comply with MCL 436.1523 and MCL 436.1603 of the Michigan Liquor Control Code, PA 58 of 1998, applicants for a license must complete this statement, sign, date and return it to the Licensing Division at the above address. I, _____________________________________, of NAME _____________________________________________ STREET and NUMBER _______________________________________________________________________________________ CITY OR VILLAGE ZIP CODE COUNTY _______________________________________________________________________________________ PRINT NAME OF APPLICANT for a new or transfer of ___________________________________________________________________ TYPE OF LICENSE From Located __________________________________________________________________________________ IF TRANSFER, NAME OF SELLER at ______________________________________________________________________________ BUSINESS ADDRESS Make the following statements to the Michigan Liquor Control Commission: 1. Pursuant to MCL 436.1523 of the Liquor Code the owners of the above real estate, or each member of any partnership or Limited Liability Company, or stockholder of a Corporation (or their spouses) do not hold any position, either by appointment or election, which involves the duty to enforce any penal law of the United States of America, or the penal laws of the state of Michigan, or any penal ordinance or resolution of any municipal subdivision of the State of Michigan (civil defense volunteer police, mayors, village presidents and members of city councils who are not considered law enforcement officers). 2. Pursuant to MCL 436.1603 of the Liquor Code the owners of the above real estate, or each member of any partnership or Limited Liability Company, or stockholder of a Corporation do not hold or have an interest in any license for the manufacture or sale of alcoholic beverages at wholesale in Michigan which would be in conflict with the granting of this license. Signature of Applicant Date LC-0016 (Rev. 04/11) AUTHORITY: MCL 436.1523, 436.1603 COMPLETION: Mandatory PENALTY: No License 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