Print Form Michigan Department of Licensing and Regulatory Affairs FOR MLCC USE ONLY MICHIGAN LIQUOR CONTROL COMMISSION (MLCC) 7150 Harris Drive, P.O. Box 30005 Lansing, Michigan 48909-7505 Request ID # Business ID # SUMMARY OF FINANCES STATEMENT [Authorized by R 436.1105]] _________________________________________________________________________________________________ TOTAL COST: $ SOURCE OF FUNDS: Indicate which of the following is applicable by noting the appropriate amounts in the spaces provided; completing the necessary information requested; and attaching the required documents. Verification is not complete without the required attachments . AMOUNT $ SOURCE OF FUNDS Loans or Lines of Credit from Financial Institutions $ Loans from third parties or individuals DOCUMENTS REQUIRED TO BE SUBMITTED WITH APPLICATION: If already received: Executed copy of Mortgage or Loan Agreement, Promissory Note(s), Security Agreement, Exhibits. If not received yet: Statement of Money (LC-3008) with Letter of Commitment (if available) If already received: Executed copy of Promissory Note, Mortgage, Security Agreements, Exhibits and Affidavit of Source of Funds If not received yet: Statement of Money (LC-3008) Complete "financial institution" $ Personal funds of applicant accumulated at a financial institution $ Corporate funds accumulated at a financial institution information on Page 2 and submit letter from you financial institution verifying that information Enter previous 2 years annual gross sales: 20_____: $ __________________ 20_____: $ ___________________ Complete "financial institution" information on Page 2 and submit letter from you financial institution verifying that information $ Other $ TOTAL FUNDS Attach affidavit. American LegalNet, Inc. www.FormsWorkFlow.com Summary of Finances Statement Page 2 of 2 FINANCIAL INSTITUTION INFORMATION Name of financial institution: _______________________________________________________________________________________________ Type of Account: Checking Savings Other: __________________________________________________ Account Balance: $ ____________________________ Date: ______________________________ Name(s) on account: _________________________________________________________________________________________ Were any checks used from subject account? Yes Check number: ___________ No Funds in account were derived from: _______________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Name of financial institution: _______________________________________________________________________________________________ Type of Account: Checking Savings Other: __________________________________________________ Account Balance: $ ____________________________ Date: ______________________________ Name(s) on account: _________________________________________________________________________________________ Were any checks used from subject account? Yes Check number: ___________ No Funds in account were derived from: _______________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ THIS FORM ALONE DOES NOT CONSTITUTE FINANCIAL VERIFICATION. ATTACHMENTS ARE REQUIRED AND, IF COMMISSION APPROVAL IS OBTAINED, VERIFICATION OF RECEIPT OF THESE FUNDS MAY BE REQUIRED. WARNING: Section 1003 of the Liquor Control Code of 1998, MCL 436.2003, provides that "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 understand that false or fraudulent statements may be grounds for denial of this application or revocation of the permit issued. Applicant's Signature: ______________________________________________ Date: __________________________ THIS "SUMMARY OF FINANCES STATEMENT" IS NOT RELEASABLE UNDER THE FREEDOM OF INFORMATION ACT (FOIA) PURSUANT TO MCL 15.243, Sub (1) (a). LC-1125 (Rev. 04/11) Authority: R436.1105 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