Print Form Commission Use Only Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission (MLCC) Request ID # _______________ 7150 Harris Drive, P.O. Box 30005Lansing MI 48909-7505 REQUEST FOR LICENSE TO BE PLACED IN ESCROW INSTRUCTIONS: Fill out all lines of this request and attach the licenses before returning to the Commission. If the licenses were destroyed attach a signed affidavit attesting that the licenses were destroyed. To the Liquor Control Commission: I request that the _____________________________________________ licenses issued by the Commission in the name of ____________________________________________________________________________ at (address) _____________________________________________________________________________ d/b/a ___________________________________________________________________________________ be placed in escrow for approximately _________ months, for the following reasons: ________________________________________________________________________________________ It is my intention to: Reactivate Change Location Transfer Ownership Surrender the license(s) for cancellation Other (please describe): As soon as proper provisions can be made to do so. It is understood that the licenses will remain in escrow only until the expiration date, and will be renewed only upon receipt of the properly executed renewal forms, fees, and placement of the licenses into active operation as required by R 436.1107 of the Michigan Administrative Code. Licensee Signature: Date: Home Address: Licensee Signature: Date: Home Address: LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. LC-3103 (Rev. 04/11) CONTINUED American LegalNet, Inc. www.FormsWorkFlow.com R 436.1107, RENEWAL OF LICENSE, Rule 7 of the Michigan Administrative Code states that: (1) A license that is not in active operation shall be placed in escrow with the commission. (2) A licensee shall have only 5 licensing years after the expiration date of the escrowed license to put the license into active operation. If the licensee fails to put the license into active operation within 5 licensing years after its expiration, then all rights to the license shall terminate unless the commission has received written verification of either of the following (a) That the license or an interest in the license is the subject of litigation or estate or bankruptcy proceeding in a court of competent jurisdiction. (b) That the license was placed into escrow as a result of damage to the licensed premises by fire, flood, tornado, or other natural event that makes the licensed premises unsuitable for the operation of the business and unsafe for the public accommodation. (3) If the commission extends the length of time for which a licensee may renew the license during the pendency of litigation or estate or bankruptcy proceedings or as a result of damage to the licensed premises for the reason stated in sub rule (2) of this rule, then the licensee shall pay the required license fee for each elapsed licensing year before placing the license in active operation. (4) Except as provided in sub rule (3) of the rule, a license held in escrow with the commission shall be renewed in the same manner as an active license, including payment of all required license fees, each year by April 30. (5) A licensee who places a license in escrow with the commission shall be responsible for providing the commission with current information, in writing, for all correspondence, which includes the name, mailing address, and telephone number. (6) Not later than 90 days after the effective date of this rule, the commission shall provide or attempt to provide each licensee whose license is in escrow with a copy of this rule. (7) A license that is held in escrow with the commission on the effective date of this rule begins the 5year period allowed by sub rule (2) of this rule for a license to be held in escrow on the effective date of this rule. PLEASE BE ADVISED, AT THE TIME A REQUEST FOR RELEASE IS RECEIVED, THE COMMISSION WILL REQUIRE AN INSPECTION BY OUR ENFORCEMENT INVESTIGATOR IF THE BUSINESS HAS BEEN CLOSED FOR OVER SIX MONTHS OR A FIRE HAS OCCURRED AT THE ESTABLISHMENT. CHANGES IN THE OWNERSHIP OF THE BUSINESS OR TO THE LICENSED ESTABLISHMENT , PLEASE PROMPTLY IF YOU HAVE MADE OR WILL MAKE ANY NOTIFY THIS OFFICE AS A FULL INVESTIGATION MAY BE REQUIRED PRIOR TO THE RELEASE OF THIS LICENSE FROM ESCROW. American LegalNet, Inc. www.FormsWorkFlow.com