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O. Box 30005 Lansing MI 48909 Toll-Free 866-813-0011 - www. michigan.gov/lcc Michigan Breweries Monthly Report of Sales LCC-3859 MLCC Licensee Name Number Address City State Zip Code Phone Fax number Wholesaler/Retailer Name Address Retailer License Invoice Invoice Number Date Month Year Email Barrels 1/2 bbl. 1/4 bbl. 1/6 bbl. Cases Enter Additional Sizes/Quantities 24/12 24/16 Ounces Firkin Growler Sales to Michigan Wholesalers TOTAL MICHIGAN SALES Sales to Other States Computer reports that show this information in the same sequence may be submitted in lieu of this report. Contact 517-284-6256 for more information. Attach a copy of this report to the Michigan Beer Tax Report LCC-3803 and submit to the address at the top of this form. I certify that the information contained in this form is true and accurate to the best of my knowledge and belief. I also understand that providing false or fraudulent information is a violation of the Liquor Control Code pursuant to MCL 436. 2003. Print Name of Licensee Title LCC-3859 06-17 Signature of Licensee Date LARA is an equal opportunity employer/program. Auxiliary aids services and other reasonable accommodations are available upon request to individuals with disabilities. Michigan Department of Licensing and Regulatory Affairs Liquor Control Commission MLCC Constitution Hall - 525 W. Allegan Lansing MI 48933 Mailing address P. O. Box 30005 Lansing MI 48909 Toll-Free 866-813-0011 - www. michigan.gov/lcc Michigan Breweries Monthly Report of Sales LCC-3859 MLCC Licensee Name Number Address City State Zip Code Phone Fax number Wholesaler/Retailer Name Address Retailer License Invoice Invoice Number Date Month Year Email Barrels 1/2 bbl. 1/4 bbl. 1/6 bbl. Cases Enter Additional Sizes/Quantities 24/12 24/16 Ounces Firkin Growler Sales to Michigan Wholesalers TOTAL MICHIGAN SALES Sales to Other States Computer reports that show this information in the same sequence may be submitted in lieu of this report. Contact 517-284-6256 for more information. Attach a copy of this report to the Michigan Beer Tax Report LCC-3803 and submit to the address at the top of this form. I certify that the information contained in this form is true and accurate to the best of my knowledge and belief. I also understand that providing false or fraudulent information is a violation of the Liquor Control Code pursuant to MCL 436.

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