Annual Organization Update {LCC-302}

Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission (MLCC) Toll-Free: 866-813-0011 - www.michigan.gov/lcc Business ID: Request ID: (For MLCC Use Only) Annual Organization Update For information on licenses and permits, please visit the Liquor Control Commission's frequently asked questions website by clicking this link. The Michigan Liquor Control Code, MCL 436.1529(2), provides that, by no later than July 1 of each year, each privately held licensed corporation, limited liability company, or limited partnership shall notify the Commission as to whether any of the shares of stock in the corporation or interest in the limited liability company or the limited partnership have been transferred during the preceding licensing year. The Commission may investigate the transfer of any number of shares or any amount of interest for the purpose of ensuring compliance with this act and the rules promulgated under this act. Individuals that hold a license in their individual name do not fill out this form. Part 1 - Licensee Information Please state your name as it is filed with the State of Michigan Corporation Division. Licensee name(s): Address: City: Contact Name: Phone: Zip Code: Email Yes No Did the licensee transfer, issue, or redeem any stock, membership interest, or limited partnership interest during the past licensing year (May 1 - April 30)? If No, sign below and submit this form to the address at the bottom of this form. If Yes, sign below and submit this form to the address at the bottom of this form. Also complete the License Interest Transfer Application (Form LCC-101) and submit any agreements or affidavits for each of the transfers, issuances, or redemptions that occurred, along with any applicable inspection and license fees and documents regarding the transfers, such as trust certificates, copies of death certificates, court orders, etc. Part 2 - Signature of Licensee I certify that the information contained in this form is true and accurate to the best of my knowledge and belief. I agree to comply with all requirements of the Michigan Liquor Control Code and Administrative Rules. I also understand that providing false or fraudulent information is a violation of the Liquor Control Code pursuant to MCL 436.2003. The person signing this form has demonstrated that they have authorization to do so and have attached appropriate documentation as proof. Print Name of Licensee & Title Signature of Licensee Date Please return this completed form along with corresponding documents and fees to: Michigan Liquor Control Commission Mailing address: P.O. Box 30005, Lansing, MI 48909 Hand deliveries or overnight packages: Constitution Hall - 525 W. Allegan, Lansing, MI 48933 Fax to: 517-373-4202 American LegalNet, Inc. www.FormsWorkFlow.com LCC-302 (10-15) LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.