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 FOR MLCC USE ONLY Request ID # Business ID # STATEMENT OF MONEY LENDER FOR PARTICIPATION PERMIT [Authorized by R 436.1105] _________________________________________________________________________________________________ INSTRUCTIONS: Anyone (including applicants, stockholders, members, banks, partners, etc.) loaning money to a person obtaining an interest in a licensed business must complete the Money Lenders Statement. R 436.1105(1) (b) requires that applicants have adequate financial resources from legitimate and verifiable sources. Verification of financing is required before the Participation Permit application can be considered. Please complete this statement, sign and return it to the MLCC. I am loaning $__________________ to _________________________________________________________________ Name of Applicant Amount to obtain a Participation Permit for the licensed business located at: _________________________________________________________________________________________________ Street and Number City or Village Zip Code County The debt is secured by the following instruments: The following persons are acting as co-signers or co-makers: The debt is repayable as follows: I ___ will ____ will not have an interest in the licensed business other than as creditor for the debt listed. I ___ do ____ do not hold any position, either by appointment or election, which involves the duty to enforce any penal law of the United State of America, or the penal laws of the State of Michigan, or any penal ordinance or resolution of any municipal subdivisions of the State of Michigan. I ___ do ____ do not hold any class of license for the manufacture or sale of alcoholic beverages at wholesale in Michigan, or any interest (stockholder/member) in any class of license for the sale of alcoholic liquor in Michigan which would be in conflict with the granting of this license I am prepared to present any documentation required for verification of these funds. My occupation is: __________________________________________________________________________________ Source of Funds, current account balance and date account was opened: __________________________________ Signature of Money Lender Date LC-1127 (Rev. 04/11) Authority: R 436.1105 Completion: Mandatory Penalty: No License and/or Permit 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