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 REPORT OF LIMITED LIABILITY COMPANY MEMBERS, MANAGERS & ASSIGNEES [Authorized by MCL 436.1529 (1) and MAC R 436.1110] GENERAL INSTRUCTIONS •The provisions of MCL436.1529(1) and R 436.1110 prohibit the transfer of more than 10% of the interest of a limited liability company without the prior consent of the MLCC. A person that owns or acquires 10% or more interest in a limited liability company shall submit fingerprints. •Sections 1-9 must be completed and this report must be signed by a Manager or at least one member, if management is reserved to the members of the limited liability company, who is authorized to sign and execute documents required by the MLCC 1. Name and registered address of limited liability company 2. Type of license 3. State in which Articles of Organization filed 4. Date authorized to do business in Michigan or date Articles of Organization filed with Michigan 5. Check type of limited liability company: Corporation Division. Privately held (not traded on stock exchange) Publicly traded 6. Member/Assignee Information NAME AND ADDRESS OF MEMBERS/ASSIGNEES % OF INTEREST DATE ISSUED 1. 2. 3. 4. 5. 6. 7. 8. If more listings are needed please attach an additional page showing the same information. (continued) American LegalNet, Inc. www.FormsWorkFlow.com 7. NAMEANDADDRESS OF THE MANAGER(S) OF THE LIMITED LIABILITY COMPANY [IF NOT MEMBERS/ASSIGNEES INDICATED ABOVE] 8. NAMEANDADDRESS OF ASSIGNEES OF INTEREST OF THE LIMITED LIABILITY COMPANY [IF NOT MEMBERS/ASSIGNEES INDICATED ABOVE] 9. NAME AND ADDRESS OF DESIGNATED PERSONS AUTHORIZED TO CONDUCT BUSINESS, SIGN THE APPLICATION AND ANY DOCUMENTS REQUIRED BY THE MLCC. NOTE: ALL MEMBERS, MANAGERS & ASSIGNEES LISTED ON THIS FORM ARE CONSIDERED AUTHORIZED UNLESS EXPRESSLY EXCLUDED IN A WRITTEN AGREEMENT EXECUTED BY ALL MEMBERS THAT MUST BE PROVIDED TO THIS OFFICE. PLEASE INDICATE OTHER DESIGNEES ONLY. WARNING: The Liquor Control Code of 1998 provides as follows in Section 1003, being MCL 436.2003 “. . . 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. . .” I, certify that the information contained in this report and any attachments are complete, true and taken from the records of this limited liability company and that I understand the WARNING above. SIGNATURE: PRINT NAME: DATE: POSITION: LC-52a (Rev. 04/11) Authority: MCL 436.1529(1) and MAC R 436.1110 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