Statement Of Money Lender {LC 3008}

Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission (MLCC) Constitution Hall - 525 W. Allegan, Lansing, MI 48933 Mailing Address: PO Box 30005, Lansing, MI 48909 Toll Free (866) 813-0011 · www.michigan.gov/lcc Business ID: Request ID: (For MLCC use only) Statement of Money Lender Instructions: Anyone (including applicants, stockholders, members, banks, partners, etc.) loaning money for the purchase of interest in a license or proposed licensed business, must complete this Statement of Money Lender. Administrative rule 436.1105(b) requires that applicants have adequate financial resources for the proposed licensed business. This rule requires the finances to be from legitimate and verifiable resources. Your verification of financing is required before the license application can be considered. Please complete this statement, sign and return it to the Commission. Money Lender Name (Individual or Company): I am loaning $ Amount to Name of Applicant for the purchase of: the licensed business (and real estate, if applicable) The debt is secured by the following instruments: inventory stock or membership interest in licensed business The following persons are acting as co-signors or co-makers: The debt is repayable as follows: Will you have an interest in the licensed business, other than as a creditor for the debt listed? Do you have Law Enforcement Powers? Yes No Yes No Yes No Do you have an interest in a retail, manufacturer, or wholesale license? Licensee(s) Name(s): If yes, list the name(s) of the licensee(s) below. I am prepared to present any documentation required for verification of these funds. My occupation is My bank accounts are located at: Signature of Money Lender Date LC-3008 (Rev. 10/15) Printed Name of Signer Title American LegalNet, Inc. www.FormsWorkFlow.com